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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM BR COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEMMARK ONLY ❑ 1 NEW PERMIT ONE ITEM ❑ ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED ONSITE ❑ e TEMPORARY TANK CLOSURE 154 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: B TANK REMOVED 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS- A. OWNER'S TANK I.D.a SPECIFY IF UNKNOWN C. DATE IN57ALLE0(MO/DAV/YEAR) B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B G ❑ 1aPNLE IUM ❑ 3 DIESEL ❑ g AVIATION❑ 2 PETROLEUM ❑ W EMPTY ❑ ❑ 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 99 ETMEq (DESCRIBE IN ITEM D. BELOW) C A S a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E . �f r A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER J SYSTEM 2 SINGLE WALL ❑ ❑ 95 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE113 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM (PrimaryTank) ❑ g BRONZE ❑ 8 1009: METHANOL COMPATIBLE WiFRp ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED •,�,� IS LINING MATERIAL COMPATIBL H 1009: METHANOL? ❑ 95 UNKNOWN Jfi 99 OTHER YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 3 VINYL Wqqp ❑ d FIBERGLASS ❑ 5 CATHODIC PROTECTION>r9l NONE REINFORCED PLASTIC E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(Y ❑� UNKNOWN El 99 OTHER OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND SOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 99 OTHER C. MATERIAL AND A U BARE STEEL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM p U a CONCRETE PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 7 STEEL WI ORATING A U g 100% METHANOL COMPATIBLE W/Fgp D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR A U 95 UNKNOWN A U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING � 3 V.TANK LEAK DETECTION MONRoRINc X 99 OTHER ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER VL TANK CLOSURE INFORMATION 1.ESTIM T=p D TE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING GALLONS 3.WAS TANK FILLED WITH YES NOX THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE IRRINTED a SIGNANRE)APPLICANTS NAME BEST OF MY KNO INERT LEDGE, IS TRUE AN❑D CORRECT DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Re, C_ 3 b STATE I.D.# COUNTYu JURISDICTION FACI�� l0 PERMIT NUMBER m TANK p PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORM A HAS BE FILE s FORMS (12-91) FILE THIS FORM WITHifLOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST AGE TANK REGULATIO 6.2 0 —CT-5 FO S-R6