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STATE OF CALIFORNIA _ STATE WATER RESOURCES CONTROL BOARD 3` f`kL r UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM H COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �'�• ��`' MARK ONLY ❑ 1 NEW PERMIT3 RENEWAL PERMIT ❑ ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1S DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.ar of B. MANUFACTURED BY: y f C. DATE INSTALLED(MOIDAYIYEAR) I 6 D. TANK CAPACITY IN GALLONS: 5 /! II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. i MOTOR VEHICLE FUEL ❑ 4 OIL g EGULAR C. UNLEAD€D 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY �PROOUCT ❑ lb PREMIUM 4 GASAHOL ❑ 7 METHANOL 3 CHEMICALPROOUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 2 LEADED ❑ g9 OTHER (DESCRIBE IN ITEM D. BELOW), 0. IF(A.1)IS NOT MARKED, EN7ER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [;;I RRNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR I❑ 5 GLASS LINING ❑ B UNLINED IKNO W N ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE tpWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE e) 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH <i7 y5 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 B CONCRETE A U 7 STEEL W!COATING A U B 1DD% METHANOL COMPATIBLE WJFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U�'! UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INI IzH�illl MONTGRING 1:1 99 OTHER V.TANK LEAK DETECTION ❑F1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONENKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED @ATE LAST USED(MOlDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERT MATERIAL? YES ❑ No THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PAINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.Q.NUMBER IS COMPOSED OF THE FOUR NUMBERS-BELOW—, COUNTY# JURISDICTION# ACILrfY# I TANK'# STATE I.D.# ❑❑ PERMIT NUMBER PERMITAPPROVEDBYIDATE PERMITSCRAT�OND4TE _5Z FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROM4&RS