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STSTATE WATER ATS OF OALIFORMA CBS CONTROL BOARD UNDERGROUNDSTORAGE TANK PERMIT APPLICATION•FORM 19 w COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ MZM ONE ITEM ENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION❑ ENDED PERMIT ❑ PERMANENTLY CLOSED ONBITE 8 TEMPOgpgy TANK CL08UREDBA OR FACILITY NAME a TANK REMOVED ur I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.x B. MANUFACTURED BV: C. DATE INSTALLED(MO/DAYIYEAR) / SID D. TANK CAPACITY IN GALLONS: ^�R II.TANK CONTENTS IFA-IISMARKED,COMPLETE ITEM C. D loll A, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C ❑ to REGULAR 3 DIESEL ❑ UNLEADED O e AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY 1 PRODUCT �O PREMIUM 4 GASAHOL ❑ ] METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN a 2 WASTE 2ULN�L_ 5 JET FUEL ❑ 90 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC.AND ALL THAT APPLIES IN BOXDANDE A. TYPE OF ❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM IR;?y2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT NAULTEDTANIQ F-189 OTHER B. TANK I✓J 1 RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE O 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL O 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING O 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED E�?U UNKNOWN ❑ 99 OTHER LINING , / IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO-LZ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE EP95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED MAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION Amt PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARESTEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ED 3 MDWTORING ❑ 90 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 99 OTHER A.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST SE (MO YNR) 2.ESTIMATEDOUANTITY OF 3.WAS TANK FILLED WITH VES E] NO SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS B14EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED a SIGNANREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 979-1 = PERMITNUMSER PERMIT APPROVED BYIDATE PEPMIT E%PI RATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) � �/ lI L� FOROON6R6