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N w NEW <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD z• ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ''o!° <br /> C/ n <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY i t NEW PERMIT S RENEWAL PERMIT 5 CNANG'c OF INFORMATION 7 PERMANENTLY CLO 'N Sim <br /> ONE ITEM r, 2 INTERIM PERMIT s AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED ,FTC: <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: (� T- U L �'�� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK t.0.a S. MANUFACTURED BY: O <br /> C. OATS INSTALLED IMOtDAYNEARI / 0. TANK CAPACITY IN GALLONS: l•+/U' �v <br /> II.TANKC EMS IFA-IISMARKED.COMPLETEITEMC. <br /> t MOTOR VEHICLE FUEL 1� A OIL 8. C. taWRJEGGUUL R 1 1 7 DIESEL 6 AVIATION GAS <br /> A. r LEADEDI A GASAHOL <br /> 2 PETROLEUM U w EMPTY ` I PROCIX:T 10 PREMIUM 7 METHANOL <br /> _ UNLEADED 1 <br /> 5 :ET FUEL <br /> 2 CHEMICAL PRODUCT 95 UNKNOWN I C 2 WASTE 2 LEADED OTHER (DESCRIBE IN ITEM D. 8E'w^'M <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED /(tia C.A.S.s <br /> III. TANK CON STRU ON MARK ONE ITEM ONLY IN 80%ES A,B.ANO C.ANDALLT. ATAPPLiE91NBOXDANOE <br /> A. TYPE OF = 1 DOUBLE WALL J S SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL A SECONDARY CONTAINMENT (VAULTED TANTO G 9B OTHER <br /> TANK I BARE STEEL 2 STAINLESS STEEL _ 0 FIBERGLASS 6 STEEL CLAD WI FIBERGLASS RENFORCEO PLAS"C <br /> B. MATERIAL 5 CONCRETE J 6 POLYVINYL CHLORIDE 7 ALUMINUM 6 I m METHANOL COMPATIBLE'N/FRP <br /> (Pnmary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN C W OTHER <br /> t RUBBER LINEA 2 ALKYD LINING 0 EPDXY -NM 6 PHENOLIC LINING <br /> C.INTERIOR J 5 GLASS LINING :J 6 UNUNEO i_• 95 UNKNOWN ❑ N OTHER <br /> UNING <br /> IS LINING MATERIAL COMPATIBLE WITH 100Y. METHANOL? YES— NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAP = 2 COATING r' 9 VINYL WRAP t A FIBERGLASS REINFORCED PLAST'C <br /> PROTECTION 5 CATHODIC PROTECTION !J 91 NCNE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEW) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION p V 2 PRESSURE A U S GRAVITY A U W OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE 'HALL A fi 2 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 2 POLYVINYL CHLORIDE IPVCIA V a FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WrCOAnNG A U 6 10U 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 1 AUTOMATIC LINE LEAK DETECTOR E 2 LINE TGHTNESSTESTING LJ I IIDNRDRING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK INVENTORY RECONCILIATION ] VADOZE MONITORING a AUTOMATIC TANK GAUGING� 5 GROUNDWATER MONITORING <br /> 8 TANK TESTING ] INTERSTITIALMONITORING J! 91 NONE r 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2 ESTIMATED GUANTITYOF 2.WAS TANK FILLED WITH YES NO r <br /> SUBSTANCE REMAINING GALLONS I INERT MATERIAL? — <br /> THIS FORM HAS BEEN COMPLETED UNDER PENA LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME CATE <br /> vRINTED a SIGNATUREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOWI r I <br /> COUNTY 6 JURISDICTION 6 FACILITY 6 TANK X 1 <br /> STATE I.D. `3 / L�3 �3 Z= Z.3 z- U <br /> -ERMIT NUMBER PERMIT APPROVED BYtDATE <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 TUM ^.AL AGENCY IMPLEMENTING THE UNDERGROUND STORACM TANREGULATIONS r <br /> =CFAt B 1'2.90 )kmw FCIE=3 & <br /> iAl <br />