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STATE OFCAUWRNrA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM S �o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, h, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT r — ONE(TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SITE 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVEC DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.x I B. MANUFACTURED BY ¢� C. DATE INSTALLED(MO/DAY/YEAR) Z 0. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETEITEM C. A. .j.( i_ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B• taAEGULAR I�� ❑"' 2 PETROLEUM C,� UNLEADED u 4 DIESEL ❑ 6 AVIATIONGAS ❑ 80 EMPTY � t PRODUCT ❑ lb PREMIUM LLLJJJ ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑SU95 UNKNOWN ❑ 2 WASTE UNLEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D 5 JETFUEL ❑ j 0. IF(A,1)IS NOT MARKED, ENTER NAME OF BSTANCE STORED 2 C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ ❑ 1000% MET14ANOL COMPATIBLEW/FRP ❑ t RUBBER LINED ❑ 2 ALKYD LINING UNKNOWN 8 ING (^ ❑ OTHER C.INTERIOR elV 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING >10, GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION U I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE CORROSION A U 5 ALUMINUM (PVC) U FIBERGLASS PIPE i A U 6 CONCRETE A U 7 STEEIw/COAnNG A U 8 t00X METHANOL C.OMPATIBIEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION W 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 UNE TIGHTNESS TESTING 3 MONITOR bIG ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING X 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1,ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTTTY OF S 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY APPLICANTS NAME KNOWLEDGE IS TRUE AND CORRECT (PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE i.D.# C�OUNI TY# JURISDICTION# DFACILIaTY TANK#�tl i 1 PERMITNUMBER PERMIT APPROVEDBY/OATE *PERMITEAIAAT�10�NOATE 4 B THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FOR&A A HAS BEEN PILED. FILE THIS FORM WITH-7;F LOCAL NCY IMPLEMENTING THE UNDERGROUND STORAGE 7,� :GULAT)ONS G� PORM B (12.91) lT'l 6 I r �.7A"l�� r FQR06348-Fi6