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�I p� �S <br /> STATE OF CALIFORNIA <br /> B <br /> STATE WATER RESOURCES CONTROL BOARD ;y"'c$� a o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B o <br /> \ w // <br /> ffCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOS SI <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT r e TEMPORARY TANK CLOSURE 6 TANK REMOVED <br /> IBA OR FACILITY NAME WHERE TANK IS INSTALLED: QDL <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. <br /> OW <br /> TANK I.D.0 / B. MANUFACTURED BY: / <br /> C. DATE INSTALLED(MWOAYYEAR) O. TANK CAPACITY IN GALLONS: /D DOO <br /> II.TANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> AVIATIONGAS <br /> A 1 MOTOR VEHICLE FUEL F7 4 OIL B...��//�1 C- 1aUNLEA ED e 4 GASAHOL O 7 METHANOL <br /> 0 2 PETROLEUM 60 EMPTY }�L,1 PRODUCT O 19UN FADED 5 JET FUEL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN /❑-2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOYJ) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 UBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 31 LE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANp 0 98 OTHER <br /> 1 BARES EL 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK O 9 POLYVINYL CHLORIDE � 7 ALUMINUM O 6 10D% METHANOL COMPATIBLE W/FRP <br /> MATERIAL Q 5 CONCRE <br /> (PNmwyTAnp 9 BRONZE a 10 GALVANIZED STEEL O 95 UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED 0 2 ALKYD LINING O 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED O 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE ITN 100%METHANOL? YES_ NO_ <br /> D.CORROSION � 1 POLYETHYLENE WRAP O COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION 91 E E]95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAMMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U I\FUwERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U / 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 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 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U STEEL WI COATING A U 6 100% METHANOL COMPATISLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TEST O mONRORING 1:j 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 77 1 VISUAL CHECK [--] 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGINGE] 5 GROUNDWATER MONITORING <br /> O 6 TANK TESTING � 7 INTERSTITIAL MONITORING 0 91 NONE O 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTI! D LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES O NO O <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 /> IPRINMD 6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW eL' I D .;31117 <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# m <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS -' <br /> FORM 8 (12-91) gf��Al � g_I R-9�'��� FURatt11696 <br />