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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BL-2 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY i NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY LO SI <br /> ONE REM F-12 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE 0 6 TANK REMOV 11 O <br /> DBA OR FACILITY NAME WHERE TANK IS IN <br /> I. TANK DESCRIPTION COMPLE ALL ITEMS- SPECIFY NKNOWN <br /> A. OWNERS TANK I.D.# B. MANUFACTURED BV <br /> C. DATE INSTALLED(MO/DAYNEAR) f D. TANK CAPACITY IN GALLONS:VL <br /> ILTANKCONTENTS IFA-1 IS MARKEKOMPLETE ITEM C-",/ <br /> A. 1 MOTOR VEHICLE FUEL 4 B. C 1e REGUL 3 DIESEL GAS <br /> UNLEADED <br /> O 2 PETROLEUM O BO EMPTY 1 PRODUCT O 1bUN UNLEADED 0 5 JET FUEL O 7 METHANOL <br /> O 3 CHEMICAL PRODUCT 0 95 UNKNOWN 0 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.R: <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 F-1 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM F7 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL 0 3 FIBERGLASS 0 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE M 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 6 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTurk) [-] 9 BRONZE E::] 10 GALVANIZED STEEL D 95 UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR F7 5 GLASS LINING 6 UNLINED O 95 UNKNOWN O 99 OTHER <br /> UNING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— <br /> D.CORROSION F7 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION a 91 NONE 0 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATIM CIRCLE AIFABOVEGROUNDORUIFUNDERGROUNO,BOTHIFAPPLICABLE <br /> A. SYSTEM TYPE U SUCTION A U PflESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 1 SINGLE WALL A U 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) U 4 ISERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING p 6 100% METHANOL COMPATIBLEW/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 O 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING 3 NIERSTITIAL <br /> 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING 0 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES O NOO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, I TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 6 SIGNATDRE) / <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# (-/{ Z (91 u �j- <br /> PERMITNUMBER PERMIT APPROVED BY/DATE '�-'�� 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 V\\�' <br /> FORMS (12-91) ' <br /> J FOROON 6 <br />