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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD p Wim, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O i NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION PERMAN TLV CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a TANK REMOVED 09 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z'L 'E- <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA.1 IS MARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B. C. REGULAR <br /> 3 DIESEL 6 AVIATION GAS <br /> O 2 PETROLEUM O 60 EMPTY O 1 PRODUCT 10PREMIUM 4 GASAHOL 7 METHANOL <br /> O UNLEADED 5 JETFUEL 0 <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN O 2 WASTE O 2 LEADED E] 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A,S.ANDC,AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 DOUBLE WALL Ej 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE F__1 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.IN <br /> LINING F—] 5 GLASS LINING O 6 UNLINED 95 UNKNOWN O 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION F—] 1 POLYETHYLENE WRAP D 2 COATING 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 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 A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN <br /> A U w OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 10D% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING I] 3 MONRORING E99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 0 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE L S M 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? <br /> TH/S FORM HAS EEN 110MPI TED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICTS NAME <br /> IPR'. aANSIGNANREI DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD.# m <br /> PERMIT NUMBER PERMIT APPROVED BY/DAlt PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT 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 /> FORMS (12-91) <br /> �-�C/ FORO9l6B116 <br />