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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B y <br /> COMPLETE A SEPARATE FORM FOR EAPH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT C 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONS"7 <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> DSA OR FACILITY NAME WHERE TANK IS INSTALLED: 's <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> _ . <br /> A. OWNER'S TANK I.D.R B. MANUFACTURED BY: tag <br /> OIL- <br /> C. DATE INSTALLED(MOiDAY.NEAR) D. TANK CAPACITY IN GALLONS: <br /> IL TANK CONTENTS IFA•1ISMARKED,COMPLETE ITEM C. I" <br /> _ <br /> r <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B, C 1a REGULAR 3 DIESEL 6 AVIATIONGAS 1 <br /> UNLEADED 4 GASAHOL <br /> 2 PETROLEUM ao EMPTY Ural 1 PRODUCT 1D PREMIUM LF 7 METHANOL <br /> J� UNLEADED ❑ 5 JET FUEL <br /> F73 CHEMICAL PRODUCT 95 UNKNOWN E] 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D, BEL <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES_IN BOX D AND E <br /> A. TYPE OF 1 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM B 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTank) 9 BRONZE TO GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING GR <br /> C.IN 5 GLASS LINING 6 UNLINED I� 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO— <br /> D.CORROSION ❑ i POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 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 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A 0 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 6 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> INTIRSTIllAL <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONITORING ❑ 99 OTHER <br /> V.TANK LEAK [DETECTION <br /> 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> Vl.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED TE AST S D(MOIOAYIYR) I 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH YES ❑ NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PEPJUF?Y,AND TO THE BEST OF MY KNOWLEDGE, IS TPUE AND COPPECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 6 SIrNRTURE9 <br /> LOCAL AGENCY USE ONLY THE STATE I.Q.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE l.D.# , �, org <br /> PERMIT NUMBER ! PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE' <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM 13 (12-91) FORD0348-M <br />