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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a_ <br /> PERMITUNDERGROUND STORAGE TANK io <br /> rrm <br /> COMPLETE A'SPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK'ONLY F-] 1 NEW PERMIT F-] 3 RENEWAL PERMIT [:e-5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE F--] 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A IFAC— N 0 Zo 93 <br /> I. TANK DESCRIPTIONCOMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK 1.D.# ,„Ut4 B. MANUFACTURED BY: <br /> Url ►JON.IeJ <br /> C. DATE INSTALLED(MO/DAY/YEAR) 040 ®/7-L D. TANK CAPACITY IN GALLONS: DdQ <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. � MOTOR VEHICLE FUEL a 4 OIL B, C REGULAR 3 DIESEL 6 AVIATION GAS <br /> �-y,.!' UNLEADED O 4 GASAHOL <br /> 2 PETROLEUM a 80 EMPTY L wI ' PRODUCT 1b PREMIUM 7 METHANOL <br /> UNLEADED 5 JETFUEL <br /> 0 3 CHEMICAL PRODUCT a 95 UNKNOWN 2 WASTE 2 LEADED 99 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 CONSTRUCTIONMARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF F- 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN <br /> y] <br /> SYSTEM L2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) F-] 99 OTHER <br /> B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL LYJ 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F-� 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrlmaryTank) [::] 9 BRONZE [::] 10 GALVANIZED STEEL D 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING F-] 3 EPDXY LINING F-] 4 PHENOLIC LINING <br /> C.INTERIOR � 5 GLASS LINING � UNLINED � 95 UNKNOWN a 99 OTHER <br /> LINING --- <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP �4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION E] 91 NONE E-]95 UNKNOWN F-] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPINGINFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A(D 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 1009/ 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 2 LINE TIGHTNESS TESTING 3 INTERSTI IAL <br /> MONfTORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ✓�1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING <br /> [:j?'6 TANK TESTING D 7 INTERSTITIAL MONITORING a 91 NONE ❑ 95 UNKNOWN F7 99 OTHER <br /> VI.TANK L INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED W ITH YES 0 NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> F(P <br /> PPLICANT'S NAME DATE <br /> RiN`TaEo&SIGNATURE) 'Z.• l •�? <br /> LOCAL L THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUM ERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATEL .# m <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORD B-RS <br />