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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD MAR <br /> 3 , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- F '1rIR g <br /> COMPLETE A SEPARATE FORM FOR TANK SYSTEM. P IT/SEH <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C E <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE' 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (f; (2 t ) <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.8 I B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) f D. TANK CAPACITY IN G! L-6 NS: aMn <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. ❑ 1 MOTOR VEHICLE FUEL OILB. C. ❑ la REGULAR <br /> 3 DIESEL ❑ 6 AVIATION GAS <br /> 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT lb PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED ❑ 5 JET FUEL <br /> O 3 CHEMICAL PRODUCT 95 UNKNOWN E��12 WASTE 2 LEADED r gg OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF ❑ 1 DOUBLE WALL F-1 3 SINGLE WALL WITH EXTERIOR LINER [::] 95 UNKNOWN <br /> SYSTEM V 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK E(Z 1 BARE STEEL Q 2 STAINLESS STEEL F--] 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP E 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 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 A 1 SUCTION A U 2 PRESSURE Ao 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 AM 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 FTRSTITIAL <br /> MONITRING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING F-� 4 AUTOMATIC TANK GAUGING E 5 GROUND WATER MONITORING <br /> �6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE E 95 UNKNOWN F7 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATD DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF (� 3.WAS TANK FILLED WITH <br /> 'r ( SUBSTANCE REMAINING 47/ GALLONS 'INERT MATERIAL? YES 'NO <br /> 2 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF*Y KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME _ DATE <br /> (PRINTED a SIGNATURE) y p� <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BEL4W <br /> COUNTY# JURISDICTI N# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMItWIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCO HIED BY A PERMIT APPLICATION-FORM A,UNLESS A CU ENT FORM A HAS BEEN fiL-ED. - <br /> /� �'/�V FOROaNB R5 <br />