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low <br /> STATEOFCAUFORMA W ct <br /> STATE WATER RESOURCES CONTROL BOARD 3„� .v 8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 9, � o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION �7 PERMANENTLY CLOSED O <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 8 TEMPORARY TANK CLOSURE 0 B TANK REMOVED I <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2.2 L E, 6 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN GlyJ+ <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAVNEAfl) D. TANK CAPACITY IN GALLONS: v <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A 0 1 MOTOR VEHICLE FUEL 0 4 OIL B. / C. 0 1aUNLEA REGULAR ED 3 DIESEL 8 AVIATIONGAS <br /> 0 2 PETROLEUM 0 SO EMPTY LrJ/1 PRODUCT O 10 PREMIUM 4 CASAHOL O 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 0 3 CHEMICALPRODUCT 0 95 UNKNOWN 0 2 WASTE 0 2 LEADED W 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 MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF O 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 0 95 UNKNOWN <br /> SYSTEM � 2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> �1 BARE STEEL 02 STAINLESS STEEL 0 3 FIBERGLASS 0 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 0 e POLYVINYL CHLORIDE 0 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL 5 CONCRETE <br /> (PdmvyTAOk) 0 9 BRONZE 0 10 GALVANIZED STEEL 0 95 UNKNOWN 0 W OTHER <br /> 0 1 RUBBER LINED E0 2 ALKYD LINING 0 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING .5 8 UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING T� <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP 0 2 COATING 0 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 91 NONE 095 UNKNOWN 0 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 AWU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U N OTHER <br /> C. MATERIAL AND A 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 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 /> BRSTITAL <br /> D. LEAK DETECTION 01 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 1 MONITORING w OTHER <br /> NT <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING <br /> 8 TANK TESTING 0 7 INTERSTITIAL MONITORING 0 91 NONE 0 95 UNKNOWN 0 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/OAV/YR) 2.ESTIMATED OUANTTY OF 3.WAS TANK FILLED WITH YE <br /> S NO <br /> _ESTIMATED D*LS NOSUB STA NCE REMI <br /> ANING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 6 SIGNATURE) Y <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW x # I� 73 - :Z <br /> COUmN1Y# JURISDW—J# FACT D TANKZ, <br /> � <br /> STATE I.D.# <br /> PERMIT NUMBER PER MIT APPROVED BY/DATE PERM IT EXPIRATION DATE / <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �J <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS .yO <br /> FORM 8 (12-91) -) t 9/ ` �/.( FORDOMB-M <br />