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DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />I. TANK DESCRIFTIUN COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN <br />A. OWNERS TANK I.D.# S. MANUFACTURED BY: <br />C. DATE INSTALLED (M019AYNEAR) D. TANK CAPACITY IN GALLONS: <br />„�AAw nn. _ARP ._. .._... _.–"'•...._T.��.... <br />A 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />C. ❑ teREGULAR <br />UNLEA ED <br />6 AVIATION GAS <br />3 DIESEL❑ <br />❑ 2 PETROLEUM ❑ 80 EMPTY <br />/ PRO <br />STATE OF CALIFORNIA <br />; 'Fyo o?' <br />3DG(� <br />❑ 2 WASTE <br />STATE WATER RESOURCES CONTROL BOARD <br />-. a <br />W <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: <br />B. TANKyf <br />MATERIAL <br />❑ 5 CONCRETE <br />„ <br />❑ 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE W/FRP <br />STORAGE TANK PERMIT APPLICATION - FORM B <br />�:P o, <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />UNDERGROUND <br />� <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />❑ 5 GLASS LINING <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />95 UNKNOWN <br />❑ 99 OTHER <br />MARK ONLY <br />❑ <br />1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED ON 3 <br />TEMPORARY TANK CLOSURE e TANK REMOVED <br />ONE ITEM <br />❑ <br />2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B <br />WITH 100% THANOL? <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />I. TANK DESCRIFTIUN COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN <br />A. OWNERS TANK I.D.# S. MANUFACTURED BY: <br />C. DATE INSTALLED (M019AYNEAR) D. TANK CAPACITY IN GALLONS: <br />„�AAw nn. _ARP ._. .._... _.–"'•...._T.��.... <br />A 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />C. ❑ teREGULAR <br />UNLEA ED <br />6 AVIATION GAS <br />3 DIESEL❑ <br />❑ 2 PETROLEUM ❑ 80 EMPTY <br />/ PRO <br />❑ lb PREMIUM <br />4 GASAHOL <br />7 METHANOL <br />❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN <br />❑ 2 WASTE <br />UNLEADED <br />❑ 2 LEADED <br />J_5JET FUEL <br />99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: <br />111 TANK CONSTRIICTION MARK ONF ITFM ONLY IN BOXES A.B.AND C. AND ALL THAT APPLIES IN BOX D AND <br />A. TYPE OF <br />❑ 1 BL ALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 95 UNKNOWN <br />SYSTEM <br />2 GLE WALL <br />❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) <br />❑ 99 OTHER <br />CONSTRUCTION <br />1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBER0LASS REINFORCED PLASTIC <br />B. TANKyf <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 8 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE W/FRP <br />(PrimvyTmk) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />LEAK DETECTION <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />❑ 5 GLASS LINING <br />❑ 8 UNLINED <br />95 UNKNOWN <br />❑ 99 OTHER <br />LINING <br />IS LINING MATERIAL COMPATIBLE <br />WITH 100% THANOL? <br />YES_ NO— <br />D. CORROSION <br />❑ 1 POLYETHYLENE WRAP <br />-DATING <br />❑ 3 VINYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PR0TECTION <br />91 NONE <br />❑95 UNKNOWN <br />O 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE <br />A. <br />SYSTEM TYPE <br />A& <br />1 SUCTION <br />A U <br />2 PRESSURE A U <br />3 GRAVITY A U 99 OTHER <br />B. <br />CONSTRUCTION <br />U <br />1 SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br />C. <br />MATERIAL AND <br />CORROSION <br />PROTECTION <br />A <br />A U <br />A U <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZEDSTEEL <br />A U <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />S CONCRETE A U <br />10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC)A U <br />7 STEEL W/ COATING A U <br />/A U 95 UNKNOWNU <br />4 FIBERGLASS PIPE <br />B 100% METHANOL COMPATIBLE W/FRP <br />90 OTHER Ljj <br />�,Y� <br />D. <br />LEAK DETECTION <br />❑ 1 <br />AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING <br />❑ 99 OTHER <br />V. TANK LEAK DETECTION <br />❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUT TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br />❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 0 91 NONE 95 UNKNOWN ❑ 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES NO <br />LA^��d'l, 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 />APPLICANTS NAME DATE <br />(PRINTED 6 SIGNANRE) <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.# m U 5 % 1610151611YIAy <br />PERMIT NUMB rn a 3.8o PER MIT 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 T: R LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST9AlGE TANK REGULATIONS <br />FORM B(12-91) f FOROm1BR6 <br />N <br />