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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD p ••` • "'� ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B = yI=1 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY F-1 I NEW PERMIT F� 0 RENEWAL PERMIT rL( 5 CHANGE OF INFORMATION 7 PERMANENTLYCLO S TE <br /> ONE REM F7 2 INTERIM PERMIT F76 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE J 8 TANK REMOVED)/ <br /> EMOVED / <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: C kurve, 4F 90 SS 7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.9 Y ( B. MANUFACTURED BY: C06r <br /> C. DATE INSTALLED(MOfOAY/YEAR) i94c D. TANK CAPACITY IN GALLONS: IC DCO <br /> ILTANKCONTENTS IFA•11SMARKEO.COMPLETE ITEM C. <br /> A F�Nj I MOTOR VEHICLE FUEL 4 OIL B. to FEGUUR S DIESEL 6 AVIATpNGAS <br /> U EGULA O <br /> 2 PETROLEUM 80 EMPTY © 1 PRODUCT , bPR OED H 5 GASAHJET EL 7 METHANOL <br /> UNLEAO O CHEMICAL PRODUCT 95 UNKNOWN a 2 WASTE 2 LEADED 99 OTHER (ESCRIBE IN ITEM O.SELOWI <br /> 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.S: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF I DOUBLE WALL 7 SINGLE WALL WITH EXTERIOR LINER Cj 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) C 99 OTHER <br /> B. TANK I BARE STEEL 2 STAINLESS STEEL O F113ERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE ^� 8 POLYVINYL CHLORO C 7 ALUMINUM I_ 8 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) I� 9 BRONZE I 10 GALVANIZED STEEL W UNKNOWN CI 99 OTHER <br /> I RU88ER LINED 2 ALKYO LINING ❑ 0 EPDXY LINING a PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING <br /> LINING [I 8 UNLINED C 95 UNKNOWN C 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING 7 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHOOICPROTECTION U 91 NONE I x. 95 UNKNOWN ❑ 99 OTHER <br /> E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNCERGROUNO.BOTHIFAPPLICABLE <br /> A. SYSTEM TYPE A& 1 SUCTION A U 2 PRESSURE A U 2 GRAVITY A U W OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A D 2 DOUBLE WALL A U 5 LINED TRENCH A U 95 UNKNOWN A U 9a OTHER <br /> C. MATERIAL AND A U 1 SAFE STEEL A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A q 7 STEEL W/COATING A U 8 100% .METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U W OTHER <br /> D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTINGjg O"EuoNRORMG ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 76 1 VISUAL CHECK L� 2 INVENTORY RECONCILIATION 0 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING Q 5 GROUND WATER MONITORING <br /> TANK TESTING Q 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED(MO/DAY/YF) 2.ESTIMATED OUANTITY OF 0.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING S INERT MATERIAL? YES D NO � <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU MD T OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> IPiYNTEO a 9KilM1LRE1 <br /> I�VLo rs �er1alS„J 4-/6 -53 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTXE F UR NUMBERS BELOW J <br /> COUNTY x JURISDICTION 9 " F IUTY x TANK i <br /> STATE I.D.i* L=_JI = 1 1 1 1 1 1 1 ZE0131,711C,161 ;,.zL-- <br /> PERMITNUMBER PERMIT APPROVED SYMATE I PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PFAMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM 9 (12-91) FOR0038-116 <br />