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STATE OF CALIFORNIA <br /> �l STATE WATER RESOURCES CONTROL BOARD <br /> (� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> P <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. s <br /> MARK ONLY 1 t NEW PERMIT _ 3 RENEWAL PERMIT J CHANGE OF INFORMATION r T PERMANENTLY CkObY Sim <br /> ONE REM C 2 INTERIM PERMIT a AMENDED PERMIT 1 6 TEMPORARY TANK CLOSURE j 6 TANK REMOVED <br /> OBAOR FACILITY NAME WHERE TANK IS INSTALLED: r4" <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.+ B. MANUFACTURED BY: <br /> C. OAT. INSTALLED 1MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: (••_ <br /> II.TANKCONTENTS IFA-11 SMARIEJ.COMPLETEITEMC. <br /> m REGULAR , ] DIESEL '^ 6 AVIATION GAS <br /> A. 1 MOTOR VEHICLE FUEL a OIL !, B. I C. UNLEADED t GASAHOL <br /> 2 PETROLEUM 160 EMPTY 1 PRODUCT lb PREMIUM l METHANOL <br /> UNLEADED 5 JET FUEL <br /> r 1 ] CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 1 2 LEADED 9g CTL <br /> (DESCRIBE IN ITEM 0. SELCWI <br /> 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.+: <br /> III. TANK CONSTRU N MMKONE ITEM ONLY IN BOXESA.&ANO C.AND ALL THAT APPLIES IN BOX 0 AND <br /> A. TYPE OF <br /> C 1 DOUBLE WALL _I 3 SINGLE WALL WITH EXTERIOR LINER 1 95 UNKNOWN <br /> SYSTEM 1 2 SINGLE WALL J a SECONDARY CONTAINMENT (VAULTED TAM ❑ 90 OTHER <br /> C <br /> 1 &ARE STEEL J 2 STAINLESS STEEL ] FIBERGLASS '1 a STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL C 5 CONCRETE 1 8 POLYVINYL CHLORIDE T ALUMINUM 8 100% METHANOL G^MPATIBLEW/FRP <br /> )PrimaryTWk) 9 BRONZE 10 GALVANIZED STEEL U 95 UNKNOWN 99 OTHER <br /> LC 1 RUBSER LINED 1 2 ALKYD LINING 7 EPDXY LINING a .PHENOLIC LINING <br /> C.INTERIOR F—I 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN 11 99 OTHER <br /> LINING <br /> IS LINING-MATERIAL COMPATIBLE WITH 100% METHANOL I YES_ NO_ <br /> D.CORROSION L� I POLYETHYLENE WRAP 1 2 COATING 3 VINYL WRAP E2< FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION I,_I 91 NONE 95 UNKNOWN 1 99 OTHER <br /> E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION ECUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A& 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 0a FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/COATING A U B 100% METHANOL COMPATBLE 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 r I AUTOMATIC LINE LEAK DETECTOR r 2 LINE TIGHTNESS TESTING 7'I!'NTEl 17 <br /> MJNRORING �_� OTHER <br /> V.TANK LEAK DETECTION <br /> U 1 VISUAL CHECK INVENTORY RECONCILIATION 1 2 VADOZE MONITORING `I. 6 AUTOMATIC TANK GAUGING J 5 GROUND WATER MONITORING <br /> � <br /> 6 TANK TESTING T INTERSTITIALMONITORING ❑ 91 NONE 1 95 UNKNOWN 1 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED IMO/DAYNM 2 ESTIMATED QUANTITY OF I WAS TANK FILLED WITH YES �'- Np r, <br /> I SUBSTANCEREMAINING GALLONS I INERT MATERIAL' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT <br /> APPLICANTS NAME <br /> MRINTED A SIGNATURfl <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW l' <br /> COUNTY 9 JURISDICTION A FACILITY x TANK x <br /> STATE 04 3 I !! Z4.3 3 . Z; Z _;I Z, o / <br /> PERMITNUMBER PERMIT APPROVED BY,'DATE P – IRAiIB <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 :AL AGENCY IMPLEMENTING THE UNDERGROUND STn- 'ANK REGULATIONS <br /> FORM 3 i t 2 91) It <br /> ` , G/�y PoP001+4R6 <br /> %% <br />