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STATEOFCAUFORNIA 0, ; <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY I NEW PERMIT F7 9 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PE3MIT ❑ A AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 6 TANK REMOVED <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN " <br /> A. OWNER'S TANK I.O.0 I S. MANUFACTURED BY: O G <br /> C. PATE INSTALLED(MdOAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKC TENTS IF A-1 IS MARKED.COMPLETE ITEM C. <br /> a <br /> A 1 MOTOR VEHICLE FUEL rl A OIL 8. / i C. REGULAR S GIESEL 6 AVIATION GAS <br /> K/ UNLEADED a GASAHOL <br /> 2 PETROLEUM I 6D EMPTY 1 PRODUCT I j to PREMIUM ! 7 METHANOL <br /> ' UNLEADED5 :ETFUEL <br /> i� 0 CHEMICAL PRODUCT F7 95 UNKNOWN -7 2 WASTE i 2 LEADED J 99 OTHER (DESCRIBE IN ITEM 0. BELOW( <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.i <br /> 111. TANK CONSTRUC ION RKONE ITEMONLY IN BOXES A.B.ANDC.ANDATMATAPPLIES INSOXOANOE <br /> A. TYPE OF 1 DOUBLE WAAIALL <br /> LL Ei 0 SINGLE WALL WITH EXTERIOR LINEA 95 UNKNOWN <br /> SYSTEM L_ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VA TEOTAN7 99 OTHER <br /> I BARE STEEL 2 STAINLESS ST'c1 0 FIBERGLASS I` A STEEL CUD'NI FIBERGLASS REINFORCED PLASTIC <br /> S. TANK = <br /> MATERIAL 5 CONCRETE � S POLYVINYL CHLORIDE r 7 ALUMINUM 9 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTisk) 9 BRONZE U 10 GALVANIZED STEEL C 95 UNKNOWN j 99 OTHER <br /> _ I RUBBER LINED 2 ALKYD L!NWG L 1 EPDXY LINING ❑ A PHENOLIC L'NING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED 95 UNW40WN j 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO— <br /> D.CORROSION I POLYETHYLENE WRAP ❑ 2 COATING G 0 VINYL WRAP _ A FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ^' 5 CATHODIC PROTECTION = 91 NONE 95 UNKNOWN 99 OTHER <br /> E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION ECUIPMENT 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 2 PRESSURE A U 0 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A C3 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 0 POLYVINYL CHLORIDE(PVC)A 04 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELYNCOATING A U a 100% METHANOL COMPATIBLEWIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> 0, LEAK DETECTION (1 I AUTOMATIC LINE LEAK DETECTOR :] 2 LNETX9HTNESSTESTNG I—I I AgNffOR1NG 90 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2VENTORY RECONCILIATION J VADOZE MONITORING ` A AUTOMATIC TANK GAUGING 5 GRCUND WATER MONITORING <br /> 6 TANK TESTING Z INTERSTITIALMONITOPING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> L ESTIMATED DATE LAST USED(MCIOAYNR) 2.ESTIMATED QUANTITY OF &'NAS TANK FILLED WITH YES NO <br /> 7� <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL �— <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME %ATE <br /> (FEINTED i SIGNATURV <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ✓, � <br /> COUNTY x JURISDICTION 9 FACILITY It TANK* <br /> STATE I.D.# j 1 L � -Z 3 U3 zv�31 <br /> PERMITNUMSER PERMITAPPROVEDSY/DATE <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 TUP I(CAL AGENCY IMPLEMENTING THE UNDERGROUND STVRAGE TANK REGULATIONS <br /> =ORM 3 112-917 v PoPom+B-�6 <br />