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0 <br />tSOVROf3 <br />STATE OF CALIFORNIA ." . cO r <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Bo <br />o <br />• Cit IFOR H,r <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br />ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN <br />A OWNER'S TANK I. D. # B. MANUFACTURED BY: <br />C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br />II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. <br />A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />❑ 2 PETROLEUM ❑ 80 EMPTY <br />❑ 1 PRODUCT <br />❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL <br />❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 <br />❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN <br />❑ 2 WASTE <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <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, B, AND C, AND ALL THAT APPLIES IN BOX D AND E <br />A. TYPE OF <br />❑ 1 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br />SYSTEM <br />❑ 2 SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />❑ 99 OTHER <br />B. TANK <br />❑ 1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 100% METHANOL COMPATIBLEW/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />C. INTERIOR <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />LINING OR <br />❑ 5 GLASS LINING <br />❑ 6 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? <br />YES— NO— <br />D. EXTERIOR <br />❑ i POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL, 81C. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE A U <br />3 GRAVITY A U <br />4 FLEXIBLE PIPING A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />i SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />CORROSION <br />PROTECTION <br />A U <br />A U <br />A U <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZED STEEL <br />A U <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE <br />7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br />A U 95 UNKNOWN A U 99 OTHER <br />D. LEAK DETECTION <br />7 <br />1 MECHANICAL UNE LEAK F-� <br />DETECTOR <br />2 LINE TIGHTNESS F73 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC LINE E <br />TESTING MONITORING LEAK DETECTOR <br />5 AUTOMATIC PUMP [:]99 OTHER <br />SHUTDOWN <br />V. TANK LEAK DETECTION <br />F-1 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL INVENTORY ❑ 3 MONITORING VADOZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER ❑ 6 TESTINGTANK <br />❑ 7 <br />MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 ANEK GA GAINGAL ❑ 10 TE <br />TINGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER <br />VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) <br />1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL ? <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME DATE <br />(PRINTED E SIGNATURE) —7 <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY # TANK # I <br />STATE I.D.4 m1-114/l/TF01/1 <br />PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE `7V $/7 <br />Wit CnDU ul ICT Q0 ArrnMloAAIIPn uv a PrQUIT Baal ICATInN . FnRM e_ UNLFSS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR Ik$TALLATIONS. THIS FOR! <br />FORM B (6.95) <br />SHOULD BE ACCOMPANIED BY A PLOT PL6FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION <br />F0R0034B•R7 <br />