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�yuursces <br /> STATE OF CAUFOFHA ...... <br /> STATE WATER RESOURCES CONTROL BOARD 3 �, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W �° <br /> co o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY a 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.X l,) B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: C) <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A [J 1 MOTOR VEHICLE FUEL 4 OIL B. C to REGULAR 3 DIESEL 6 AVIATION GAS <br /> UNLEADED 4 GASAHOL <br /> 2 PETROLEUM a 80 EMPTY a 1 PRODUCT a lbPREMIUM <br /> 5 JET FUEL 7 METHANOL <br /> UNLEADED <br /> 3 CHEMICAL PRODUCT F-1 95 UNKNOWN E:j 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOV,� <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: <br /> III. TANK CONSTRU 'BION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF Q 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) F7 99 OTHER <br /> B. TANK <br /> 0 1 BARE STEEL a 2 STAINLESS STEEL F--] 3 FIBERGLASS = 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 0' 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE a 1✓✓0 GALVANIZED STEEL a 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED ALKYD LINING 3 EPDXY LINING a 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 8 UNLINED <br /> LINING 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO <br /> D.CORROSION 1 POLYETHYLENE WRAP a 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <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 A 2 DOUBLE WALL A V 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 100^i 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 /> D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR a 2 LINE TIGHTNESS TESTING 0 3 INTERSTITIAL D 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> a 1 VISUAL CHECK 2,4INVENTORY RECONCILIATION 3 VAPOR MONITORING a 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH r <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO <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 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> ""'"l lt4- COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# �'�1 F �I �� l 4' 7 1 17F; (IMI V <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORMS (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMrr APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR00348.R4 <br />