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Fl <br /> a�.ou <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a`� , 9° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °®`,FoRN <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT Eig 5 CHANGE OF INFORMATION 07 PERMANENTLY CLOSED 0ITE <br /> ONE ITEM a 2 INTERIM PERMIT F-1 4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED IYA <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: n r F �� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# v f B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) l D. TANK CAPACITY IN GALLONS: 41,6909 <br /> II.TANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 12 <br /> A. 0la REGULAR <br /> 3 DIESEL <br /> 1 MOTOR VEHICLE FUEL 4 OIL g. C, 6 AVIATION GAS <br /> 2 PETROLEUM F-180 EMPTY 1 PRODUCT tb PREMIUM 4 GASOHOL 7 METHANOL <br /> F--] <br /> O a a 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED UNLEADED E:] <br /> 99 OTHER RJET L(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,B,AND C,AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF F-� 1 DOUBLE WALL [--] 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL F-1 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK F-] 1 BARE STEEL F] 2 STAINLESS STEEL Q 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F-1 6 POLYVINYL CHLORIDE F-17 ALUMINUM E::] 8 10D% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 0 10 GALVANIZED STEEL 95 UNKNOWN a 99 OTHER <br /> a 1 RUBBER LINED 2 ALKYD LINING V96 <br /> EPDXY LINING � 4 PHENOLIC LINING <br /> C.INTERIOR F-15 GLASS LINING D6 UNLINED UNKNOWN a 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH /0D%METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP F--j 2 COATING V95 <br /> VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION D 91 NONE UNKNOWN O 99 OTHER <br /> IV.PIPING INFORM T CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> 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 <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% 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 0 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK F-] 2 INVENTORY RECONCILIATION F---1 3 VAPOR MONITORING E] 4 AUTOMATIC TANK GAUGING E] 5 GROUND WATER MONITORING <br /> 0 6 TANK TESTING a 7 INTERSTITIAL MONITORING 91 NONE E::] 95 UNKNOWN E] 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 <br /> SUBSTANCEREMAINING GALLONS INERTMATERIAL? 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&SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE ATE q//2 <br /> /?/- <br /> FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FOR0M46-R4 <br />