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(ND-N. <br /> �' STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION w FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM F-� 2 INTERIM PERMIT 4 AMENDED PERMIT B TEMPORY TANK CLOSURE 0 8 TANK REMOVED 1V <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 Y <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# v B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOtDAYREAR) D. TANK CAPACITY IN GALLONS: /Tj� ppU <br /> ILTANKCONTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. Q 1a REGU AR 3 DIESEL e AVIATIONGAS <br /> 2 PETROLEUM BO EMPTY 1 PRODUCT 1b PREMIUM 4 GASAHOL � 7 METHANOL <br /> O O UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED P099 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED��� E v/G 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 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> B. TANK1 BARE STEEL E:] 2 STAINLESS STEEL F-� 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE 8 POLYVINYL CHLORIDE 7 ALUMINUM B 100% METHANOL COMPATIBLE WIFRP <br /> (PdmwyTNk) O 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION 0 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [—] 5 CATHODIC PROTECTION 0 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U / BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION E] 1 AUTOMATIC LINE LEAK DETECTOR E 2 UNETIGHTNESS TESTING Q 7 L10NRORING O W OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 0 8 TANK TESTING 0 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 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 L NO <br /> SUBSTANCE REMAINING GALLONS I 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 /> IPRINTEO 4 SWNANRE) <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.Dl mSlo 3 3 6 k n <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE F—r/ x / <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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS V\ <br /> FORM B (1291) \ 81111 <br />