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n FybJ R F <br /> STATE OFCALIFORNIA <br /> CON ^� °°i. <br /> STATE WATER RESOURCES CONTROL BOARD W��, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;b ce <br /> / �; . <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �"°""1" <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM F7 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED Aw <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: , <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# OZ- B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) a D. TANK CAPACITY IN GALLONS: <br /> II.TANK ENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. <br /> 1 MOTOR VEHICLE FUEL 4 OILB. C. Q 1aUNLEA ll ED 3 DIESEL 6 AVIATION GAS <br /> 0 2 PETROLEUM 80 EMPTY 1 PRODUCT O 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED 0 5 JETFUEL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE 0 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.9: <br /> III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF ❑ / DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM O 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> B. TANK F-1 1 BARE STEEL 0 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 0 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN W OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 6 UNLINED 95 UNKNOW O 99 OTHER <br /> LINING u/nK� <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO <br /> D.CORROSION F-1 1 POLYETHYLENE WRAP F72 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 0 91 NONE O95 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 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 6 CONCRETE A U 7 STEEL W/COATING <br /> A U 6 100% 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 Q 1 AUTOMATIC LINE LEAK DETECTOR [_] 2 LINE TIGHTNESS TESTING 3 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING O 91 NONE 0 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LA�j US D O/DAV 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> lb SUBSTANCE REMAINING GALLONS INERT MATERIALi YES ONO <br /> THIS FORM HAS BEEN COM LETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> (PRINTED <br /> APPLICANTBIGN4TURENAME S DATE <br /> a I <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBE <br /> COUNTY# JURISDICTION# ACILITY# TANK# - <br /> STATE I.D. all = I Id I I E � <br /> PERMITNUMBER PERM IT APPROVED BV/DATE PE IT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> ' � FOBpro4BA5 <br />