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W-mr�. Pr 5°��- , STATE OF CALIFORNIA fie! STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BIt ua COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: .>/l I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: [/ C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUNLEADED REGULAR 3 DIESEL 6 AVIATION GAS 2 PETROLEUM 80 EMPTY _1 PRODUCT tbPREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL 3 CHEMICAL PRODUCT F—] 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL [--] 3 SINGLE WALL WITH EXTERIOR LINER E:l 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F--] 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 4 PHENOLIC LINING C.INTERIOR F-1 5 GLASS LINING 6 UNLINED 95 UNKNOWN a 99 OTHER LINING — IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP F-] 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION D 5 CATHODIC PROTECTION 0 91 NONE 95 UNKNOWN ❑ 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 jlUiSUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 SINGE 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 STEELW/COATING A U 8 100°/ METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION As-a UNKNOWN A U 99 OTHER D. LEAK DETECTION1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTERSTI IAL 99 OTHER ❑ ❑ ❑ MONfTORING [:] V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 17F6 TANK TESTING 7 INTERSTITIAL MONITORING F-7 91 NONE E] 95 UNKNOWN E:l 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# �' ` PERMITNUMBER PERMIT APPROVEDBY/DATE PERMIT EXPIRATION DATE , g' ii THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (12-91) FOR0034111116 _.,, ..A��a� .: _- - ,-�_;. .4..= .•ALL ...n n��r ., •y..�w . .�. _ __. ..., :.x...,,,_ _�'"5