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STATE OFCALIFORMA a <br />STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ON SITE <br />ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED <br />OBA OR FACILITY NAME WHERE TANK IS INSTALLED: / 0' A ,.,, .. _ _ L! _ <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'DAYMEAR) &vvV D. TANK CAPACITY IN GALLONS: <br />II. TANK CONTENTS IPA_.IRY <br />A. ❑ 1 MOTOR VEHICLE FUEL <br />Ill. <br />4 OIL <br />B. <br />C. Ia REGUL R <br />3 DIESEL <br />E] 6 AVIATION GAS <br />0 2 PETROLEUM <br />W EMPTY <br />1 PRODUCT <br />1b PREMIUM <br />O <br />4 GASAHOL <br />7 METHANOL <br />O 3 CHEMICAL PRODUCT <br />O BS UNKNOWN <br />WASTE <br />UNLEADED <br />O 2 LEADED <br />5 JET FUEL <br />Q <br />4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />F-] 5 CONCRETE <br />O 6 POLYVINYL CHLORIDE <br />7 ALUMINUM <br />09 OTHER (DESCRIBE <br />IN ITEM O. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br />� (]. C <br />O 95 UNKNOWN <br />C. A. S. #: <br />405 - <br />5 - <br />III. TANK CONSTRUCTION MARK ONF ITEM ONI V IN RDYE9 AM eunc eun u I Tu <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF IINOFRGROI INO RDTH IF APPI MART C <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE A&I <br />A. TYPE OF <br />1 DOUBLE WALL <br />O 3 SINGLE WALL WITH EXTERIOR LINER <br />0 95 UNKNOWN <br />SYSTEM <br />2 SINGLE WALL <br />4 SECONDARY CONTAINMENT (VAULTED TANK) <br />Q 99 OTHER <br />B. TANKligr'l <br />BARE STEEL <br />0 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />F-] 5 CONCRETE <br />O 6 POLYVINYL CHLORIDE <br />7 ALUMINUM <br />8 10D% METHANOL COMPATIBLE W/FRP <br />(P11mwyTMlk) <br />09 BRONZE <br />0 10 GALVANIZED STEEL <br />O 95 UNKNOWN <br />Ej 99 OTHER <br />O / RUBBER LINED <br />a 2 ALKYD LINING <br />O 3 EPDXY LINING <br />O 4 PHENOLIC LINING <br />C INLINING TERI <br />05 GLASS LININGS <br />UNLINED <br />O 95 UNKNOWN <br />O W OTHER <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES _ NO <br />D. CORROSION <br />F-1 1 POLYETHYLENE WRAP <br />E 2 COATING <br />❑ 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />Q 5 CATHODIC PROTECTION1 NONE <br />F-1 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 IINOFRGROI INO RDTH IF APPI MART C <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE A&I <br />GRAVITY <br />A U 99 OTHER <br />B. <br />CONSTRUCTION <br />AV <br />1 SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH <br />A U 96 UNKNOWN A U 90 OTHER <br />C. <br />MATERIAL AND <br />CORROSION <br />PROTECTION <br />A <br />A <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. <br />LEAK DETECTION <br />I] 1 <br />AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING Q <br />MONRORNGW OTHER <br />V. TANK LEAK DETECTION <br />1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING 7O� 5 GROUNDWATER MONITORING <br />O 6 TANK TESTING 0 7 INTERSTITIALMONITORING 91 NONE [-] 9695 UNKNOWN 99 OTHER -'A 111 K OA A. <br />VI. TANK CLOSURE INFORMATION V v <br />1. ESTIMATED DATE/1 AA�TU3ED(MO/DAY/VR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH YES O NOO <br />J%IL SUBSTANCE REMAINING GALLONS INERTMATERIAL? <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 A SIGRITUREI <br />33ENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW a -3 D { 0- 0 I <br />COUNTY III JURISDICTION# FACILITY# 11101,7616111 <br />BFRSTATE I.D.# = �616111 <br />BER PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. <br />FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM B (1291) ( I I (e O /-'* <br />, FOR�A� <br />yai 1 <br />