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x <br /> c. 0 P�b.0 M< Cp <br /> STATE OF FO A :r a <br /> STATE WATER RESOURCES CONTROL BOARD a ►, <br /> UNDERGROUND STORAGE TANK PERMITAPPLICATION- FORM a <br /> COMPLETE A SEPARATE FO -E H TANK SYSTE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENE�CRMIT 5 CHANGE OF INFORMATION 7 PE NENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 ,AMI NDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK R VED_ <br /> DBA OR FACILITY NAME WHERE TANK IS INSTAL &I, I tq ' � J , 6,C <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# 8. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) 1 D. TANK CAPACITY IN GALLONS: <br /> II.TANK ONTENTS IFA-11SMARK ,COMPLETE ITEM C. <br /> A V 1 MOTOR VEHICLE FUEL 4 OIL C. la REGULAR <br /> E:] 3 DIESEL 6 AVIATION GAS <br /> UNLEADO 2 PETROLEUM � 80 EMPTY 1 PRODUCT a lb PREMIUM 4 GASAHOL E] 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE a 2 UNLEADED � 5 JET FUEL <br /> LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.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 F-] 3 SINGLE WALL WITH EXTERIOR LINER a 95 UNKNOWN <br /> SYSTEM [�] 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) F-1 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL a 3 FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE F--] 6 POLYVINYL CHLORIDE a 7 ALUMINUM [::] 8 10D METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE [:] 10 GALVANIZED STEEL 95 UNKNOWN Ej 99 OTHER <br /> 1 RUBBER LINED F--] 2 ALKYD LINING ❑ 3 EPDXY LINING F-� 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING F-1 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION F-] 1 POLYETHYLENE WRAP F--] 2 COATING F-] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION a 5 CATHODIC PROTECTION [::] 91 NONE E]95 UNKNOWN E:] 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 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 D 1 AUTOMATIC LINE LEAK DETECTOR [::] 2 LINE TIGHTNESS TESTING 3 MONITORING 0 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK F--] 2 INVENTORY RECONCILIATION F-] 3 VAPOR MONITORING� 4 AUTOMATIC TANK GAUGING E 5 GROUND WATER MONITORING <br /> a 6 TANK TESTING � 7 INTERSTITIAL MONITORING E:] 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 YES NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <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_NWMffRSqELOW <br /> COUNTY# JURISDICTION# =AGILITY# ANK# <br /> STATEL--j I 1� (4 014 10 11:olz) <br /> I: <br /> PERMIT NUMBER PERMIT PROV BY/DATEIT EX TION DATE <br /> FORM B (9-90) THIS UST BE ACCOMPANIED BY A PERMIT APPLICATION-F A CURRENT FORM A HAS BEEN FILED. <br /> FOR0034131-144 <br />