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a <br /> _. STATE OF CALIFORNIA -STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY 71 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O >PERMANENTLY CLOSED ON S <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE B TANK REMOVED O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: J LR" LILA40 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS.- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# �P-- B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: <br /> IL TANK COPIT ENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> A. i MOTOR VEHICLE FUEL O 4 OIL B. / C. 0 1aUNLEADE� 3 DIESEL 0 g AVIATION GAS <br /> O 2 PETROLEUM O 80 EMPTY 1 PRODUCT 0 iEPREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADED 5 JETFUEL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN E::] 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> 0. 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 <br /> A. TYPE OF 1 DUSUE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (V TEDTANK) Q 99 OTHER <br /> R. TANK <br /> 0 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F7 5 CONCRETE O 8 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE WiFRP <br /> (Primary Tank) O 9 BRONZE 0 10 GALVANIZED STEEL 0 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED 0 2 ALALKYO LINING F--] 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR a 5 GLASS LINING r-e UNLINED E�j 95�&NOWN � 99 OTHER <br /> LINING <br /> IS LININ MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ <br /> D.CORROSION r-1 1 POLYETHYLENE WRAP 2 COATING a 3 VINYL WRAPFIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 91 NONE O 95 UNKNOWN 0 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION ;?'u)2 PRESSURE A U 3 GRAVITY A U W OTHER <br /> B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER <br /> C. MATERIAL AND A U 1 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 8 CONCRETE A U STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTKO A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING O 31NTERSTITIALO 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 8 TANK TESTING O 7 INTERSTITIAL MONITORING a 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOrDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO O <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 <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 /> IPRNTED a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# S9 I Wt I <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORKIMB.R/ <br />