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tgOUw P. <br /> STATE OF CALIFORNIA + e c` <br /> GSTATE WATER RESOURCES CONTROL BOARD w e ' a s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY Q 1 NEW PERMIT a 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE a TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: zo p <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IFUNKNOWN <br /> A. OWNER'S TANK I.D.i B. MANUFACTURED BY: G <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. / C. O 1eUNELGEADE� 3 DIESEL O 6 AVIATION GAS <br /> O 2 PETROLEUM 0 80 EMPTY Ir��IT 1 PRODUCT O 1b PREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADED O 5 JETFUEL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE 0 2 LEADED 0 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.i: <br /> III. TANK CONSTRUqMN MARK ONE ITEM ONLY IN BOXESA,B,ANDC,ANDALLTHAT APPLIES INBOX D AND <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER a 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL O 4 SECONDARY CONTAINMENT NAULTEDTANK) O 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM 08 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTmk) 9 BRONZE O 10 GALVANIZED STEEL Q 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING Ljr3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING O 6 UNLINED O 95 UNKNOWN 0 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION O 91 NONE Q 95 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 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 / BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 04 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 1 AUTOMATIC LINE LEAK DETECTOR a 2 LINE TIGHTNESS TESTING MONRORINIA <br /> G ON OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK = 1 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> O 6 TANK TESTING 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NOO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED!SIGNATURE( <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.# ® 3 j 3 S 2 0 /I max- <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE P IRAi1B E Z- <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FILE THIS FORM WITH""LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST^GAGE TANK REGULATIONS <br /> FORM (12-91) 4/ %e <br />