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'`yOVRCG3 + STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD U ERGROUND STORAGE TANK PERMIT APPLICATION - FORM Bc 9 ;►: 4 f.:. O hill l COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY TE ONE ITEM INTERIM PERMIT F74 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE F78 TANK REMOV 0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS—SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.* I S. MANUFACTURED BY: D�� C. DATE INSTALLED(MO/OAYIYEAR) 0. TANK CAPACITY IN GALLONS: D 11.TANK CONTENTS IFA•11SMARKEO.COMPLETE ITEM C. A. ^ 1 MOTOR VEHICLE FUEL ❑ 4 OILB. C. ❑ is REGUL R 4 DIESELGASAHL ❑ 6 AVIATION GAS I� 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ lbUN E PREMIUM 5 JET FUEL ❑ 7 METHANOL ;J 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED (❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.ANO C.AND ALL THAT APPLIES IN BOX D A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM (❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING C:] 4 PHENOLIC LINING C.INTERIOR ❑ 5 G LINING LASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100Y.METHANOL? YES_ NO D.CORROSION ❑ 1 POIYETHYIENE WRAP �❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 9g OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 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 C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INT S IAL gy OTHER MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER Vi.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/OAY/YR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO F7SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PAINTEOaSIGNATURE) /0 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW J�G1 /I COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# C) O G PERMIT NUMBER PERMIT APPROVED BYIDATE /I� PERM IT EXPIRATION DATE FORM a (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.