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coca e <br /> °c <br /> STATE OF CALIFORNIA o iD <br /> STATE WATER RESOURCES CONTROL BOARD s ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .�� v <br /> COMPLETE A SEPARATE FORM FORE TANK SYSTEM. ��o.a�� <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE O e TANK REMOVED I5 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D QiI2cot / <br /> I. TANK DESCRIPTION COMPLETE ALL I EMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D. B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK C ENTS IFP-11SMARKED,COMPLETEITEM C. <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. to REGUL R 3 DIESEL O 6 AVIATIONGAS <br /> Q 2 PETROLEUM O 60 EMPTY 1 PRODUCT O 1b PREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADED O 5 JETFUEL <br /> 3 CHEMICALPRODUCT 0 95 UNKNOWN a 2 WASTE FV2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF 1 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F–] 5 CONCRETE F-� 6 POLYVINYL CHLORIDE O ] ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Twk) 9 BRONZE E] 10 GALVANIZED STEEL O 95 UNKNOWN O W OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING F--j 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 91 NONE O 95 UNKNOWN O 99 OTHER <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 U 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% 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 Q 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING O 3IWE STRML 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 0 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MODAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO <br /> SUBSTANCE REMAINING GALLONS I INERT MATERIAL? <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 d SIGNATUREI <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.# <br /> PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT E%PIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FORMBlM <br />