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�s ^ r <br /> rFe <br /> STATE OF CALIFORNIA y' of <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> G UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B . r° <br /> �. o <br /> x.1,.0. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O B TANK REMOVED <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# O 7. S. MANUFACTURED BY: O L <br /> C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANKC ENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. 1aUNLGULAR EADEO 3 DIESEL L 6 AVIATION GAS <br /> 4 GASAHOL <br /> O 2 PETROLEUM E:j 60 EMPTY /IPRODUCT O Ib(PREMAIDUEMD Q S JET FUEL E ] METHANOL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED O 9B OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: <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 lz 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL = 4 SECONDARY CONTAINMENT (VAULTEDTANK) = 99 OTHER <br /> 1 RARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 04 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL D S CONCRETE O B POLYVINYL CHLORIDE 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PdMWYTNA) O 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 6 UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 VES_ NO— <br /> D.CORROSION = 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E�] 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION ACU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL AD3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 04 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING 0 3 WERSMIAL <br /> MONITORING [:] W OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> O 6 TANK TESTING � INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN O W OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUB STANCE REMAINING GALLONS INERT MATERIAL] YES E NOO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPUCANTSNAME DATE <br /> IPRINTED6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# �j ® I L43 1 4� o L �, <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE ATE <br /> Z-( <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FILE THIS FORM WITH TSF LOCAL AGENCY IMPLEMENTING THE UNDERGROUNDS^GAGE TANK REGULATIONS <br /> FORMS (12-91) � �/d�j;� FOROW9 R6 <br /> \/ ((/,%, <br />