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a e <br /> STATE OF CALIFORNIA �'+ <br /> STATE WATER RESOURCES CONTROL BOARD i� �R <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B ne <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT PEIrftHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT [7] 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFYIFUNKNOWN <br /> A. OWNERS TANK I.0.i B. MANUFACTURED BY: O <br /> C. DATE INSTALLED(MO'DAYNEAR) D. TANK CAPACITY IN GALLONS: l•y U" <br /> , 00 <br /> II.TANKC ENT.S IFA-11S MARKED,COMPLETE ITEM C. <br /> A. i MOTOR VEHICLE FUEL 0 4 OIL B. C. 1aUNLEADED REGULAR 3 DIESEL g AVIATION GAS <br /> O 2 PETROLEUM 0 80 EMPTY 1 PRODUCT O 1E PREMIUM 4 GASAHOL O 7 METHANOL <br /> O <br /> UNLEADED 3 CHEMICALPRODUCT 95 UNKNOWN O 2 WASTE O 2LEADED �JLOTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(p.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED I- ph" C.A.S.S: <br /> III. TANK CONSTRU ON MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 1:1 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) E::] 99 OTHER <br /> B. TANK F-1 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE O B POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTmk) O 9 BRONZE a 10 GALVANIZED STEEL 0 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 0 6 UNLINED O 95 UNKNOWN a 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSK)N 1 POLYETHYLENE WRAP ❑ 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION [�:] 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 02 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A 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 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 O 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING 3 MONRORING O 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 0 2,INVENTORY RECONCILIATION 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O5 GROUND WATER MONITORING <br /> f 6 TANK TESTING 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO O <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 /> =TS= <br /> PPL)CANTS NAME DATE <br /> 1PRINTEG 6 SIGNRTURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# 33131 3 U <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE pEpMtrERPIRg41BN•9AT4, <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 TuS LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (12-91) <br /> 41impe /Q/� �- FOR08NBR6 <br />