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STATE OF CAUFURNA :� �` r o STATE WATER RESOURCES CONTROL BOARD W,;, '.�: UNDERGROUND STORAGE TANK PERMIT APPLICATION. FORM B :o ,;ry o 'V COMPLETE A SEPARATE FORM FOR H TANK SYSTEM MARK ONLY F7 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ S TANK REMOVED �5 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: OWT A iD Li k0 n I. TANK DESCRIPTION COMPLETE ALLITEMS- SPECIFY IF UNKNOWN A.OWNER'S TANK 1.D. Uri1(- B. MANUFACTURED BY: U,�'L C. DATE INSTALLED(MO/DAYP/EAR) Wn 0. TANK CAPACIIN GALLONS: TY OQ FYIi II.TANK CONTENTS IFAA IS MARKED.COMPLETE ITEM C. ❑ 1aUNLEA ED 8 3 DIESEL ❑ 7 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4,,,/OIL B. C. y GpgAHOL ❑ %' ❑ ❑ UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL O 2 PETROLEUM Lr.-SrG./ EMPTY 1 PRODUCT 1b PREMIUM ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALLTHAT APPLIES IN BOX 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINEA m 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANq ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 5 POLYVINYL CHLORIDE n 7�ALUMINUM ❑ 0 1005 METHANOL COMPATIBLE W/FRP MATERIAL ❑ �1U/'/ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 9B OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING EPDXY LINING ❑ d PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ S UNLINED �,,,fff 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WRl4 10096 METHANOL YES— NO— ❑ 1 POLYETHYLENE WRAP F] 2 COATING VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION [:15 CATHODIC PROTECTION ❑ 91 NONE 111��/// 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATING A U S 1005 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ II,NoT RINGL ❑ OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING E] e TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE Lr-J/95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED TV OF 3.WAS TANK FILLEDYES [:] NO REMAINING ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL?7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME IPRNTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# F ffY# r�-- TANK# STATE I.D.# q F31-91 = PERMIT NUMBER PERMIT APPROVED BY/DATE hHMII EXPIRATION DATE FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. F0190614IR1 0 0