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7 UnGES <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -M 9S 2 1�0' � <br /> EI' VIRC f V1EfdT I. WE. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.' <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT CLOS NS E <br /> ONE ITEM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REM VED U <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK t.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) �1� D. TANK CAPACITY IN GALLONS: 1 �� <br /> II.TANKC TENTS IFA-1 IS MARKED COMPLETE ITEM C. <br /> A <br /> 1 MOTOR VEHICLE FUEL F—] 4 OIL B. C F—] 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS <br /> LEADED ❑ 4 GASAHOL <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT PREMIUM ❑ 7 METHANOL <br /> UNLEADED ❑ 5 JET FUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E::] 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 CONSTRUS22N MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF Eie1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK F—] 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 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 ❑ 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 U 1 SUCTION p V2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A dP2 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 6F4 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 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR INE TIGHTNESS TESTING T RS I I L <br /> MONITORING [:] gg OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK2 NVENTORY RECONCILIATION F—] 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING [:] 5 GROUND WATER MONITORING <br /> F--] 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMAT OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ <br /> S CE REMAINikp GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER ENALTY OF PERJ Y, ND TO TH MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME /^/ DATE <br /> (PRINTED&SIGNATURE) 1,"` ' M) \ "� <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFT6 FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> Z4-771 0 p F23 <br /> PERMITNUMBER e PERMITAPP OVE BY/DATE 16E ATIONDATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- CURRENT FORM A HAS BEEN FILED. <br /> 0 it FOR00348-115 <br />