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STATEOFCAUFORMA Now <br /> A <br /> STATE WATER RESOURCES CONTROL BOARD s' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B w��OMPLETE A SEPARATE FORM FOR EA ANK SYSTEM <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM0 2 INTERIM PERMIT O 4 AMENDED PERMIT Q 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: s <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- 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 NTENTS IFA-11SMARKED,COMPLETE ITEM C. REGULARo <br /> 1 MOTOR VEHICLE FUEL O 4 OIL B. C. IQ//.1aUNLEAD D O 4 GASAHOL 3 DIESEL O 6 AVIATION GAS <br /> A O 2 PETROLEUM O 80 EMPTY 1 PRODUCT LyJ 'bUN <br /> UNLEADED D a 5 JET FUEL 0 7 METHANOL <br /> 3 CHEMICALPRODUCT O BS UNKNOWN O 2 WASTE 2 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.v: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALLTHAT APPLIES IN BOX <br /> A. TYPE OF li:l 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> O 1 BARE STEEL O 2 STAINLESS STEEL 0 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL D 5 CONCRETE O Q 0 <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL E] 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING O 6 UNLINED O 95 UNKNOWN a 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— <br /> D.CORROSION 0 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 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 IFABOVEGROUNDOR 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 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 0 2 LINE TIGHTNESS TESTING 0 3 INTERSTITIAL Q 99 OTHER <br /> RING <br /> V.TANK LEAK DETECTION <br /> I] 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING O 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> E] 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANDE 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 /> APPLICANTS NAME DATE <br /> 1PRINTED 6 SI.NATDREI <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.# 12 ab�i� <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> I 7v <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMfT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORMI R4 <br />