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��bouwcPB[• <br /> eWeep w <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORMS <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS D <br /> 6 TEMPO �I <br /> MARK ONLY 1 NEW PERMIT TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ©� <br /> FACILITY NAME WHERE TANK 1S INSTALLED: <br /> DBA OR FAZC� — <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY; , � <br /> A. OWNER'S TANK I.D.p <br /> D. TANK CAPACITY IN GALLONS: ` <br /> C. DATE INSTALLED(MOIDAYNEAR) � <br /> IL TANK CONTENTS IFA-115 MARKED.COMPLETEITEMG. ❑ iaREGULARESEL ❑ 6 AVIATION GAS <br /> A MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED 4 GASAHdL <br /> PRODUCT ❑ lb PREMIUM 5 JET FUEL ❑ 7 METHANOL <br /> 2 PETROLEUM ❑ 80 EMPTY UNLEADED ❑ <br /> 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ C. OTHER (DESCRIBE IN ITEM D. BELOW} <br /> C.A,S.x <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED <br /> LIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D <br /> 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER [:] 95 UNKNOWN <br /> A. TYPE OF ZI 99 OTHER <br /> SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) <br /> 2 STAINLESS STEEL [,�J-�ERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 1 BARE STEEL <br /> B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM � B 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL ❑ 5 CONCRETE <br /> � <br /> ❑ 10 GALVANIZED STEEL � 95 UNKNOWN � 99 OTHER <br /> (Primary Tank) 9 BRONZE <br /> ❑ � 2 ALKYD LINING ❑ 3 EPDXY LINING � 4 PHENOLIC LINING <br /> 1 RUBBER LINED <br /> C.INTERIOR 5 GLASS LINING �NLINED ❑ g5 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES <br /> ❑ 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION � 9.5—UNKNOWN 99 OTHER <br /> PROTECTION 5 CATHODIC PROTECTION 9i NONE U <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 99 OTHER <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY <br /> B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WAIL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEU <br /> EL A U 3 POLYVINYL CHLORIDE(AVC} 14 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING $ 100% METHANOL COMPATIBLEW;FRP <br /> A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> PROTECTION �–�.� STITGVL 99 OTHER <br /> D. LEAK DETECTION ❑ <br /> 1 AUTOMATIC LINE LEAK DETEC—R ❑ 2 LINE TIGHTNESS TESTING 1 p RgoRING ❑ <br /> V.TANK LEAK DETECTION <br /> �❑ 1 VISUAL CHECK �J 2 INVENTORY RECQNCILIATION � 3 VAP MONITORING� d AUTOMATIC TANKGAUGING � 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 7191 NONE <br /> 95 UNKNOWN 99 OTHER <br /> � <br /> VI.TANK CLOSURE INFORMATION 3.W�INERT <br /> ILLED WITH YES ❑ NO <br /> 2.ESTIMATED QUANTITY OF GALLONS ATERIAL? <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) SUBSTANCE REMAINING <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDDG, IS TRUE AND CORRECT <br /> APPLICANT'S NAME <br /> (PRINTED&SIGNATUR€y <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.# 5 7 m❑ <br /> PERMNUMBER <br /> PERMITAPPROVEO BY/DATE PERMIT EXPIRATION DATE <br /> IT <br /> FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORvasaB-Ra <br />