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`� yes uN <br /> SPATE OF CAl1FORNA ` <br /> STATE WATER RESOURCES CONTROL BOARD ;� y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B "m� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE S TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 47lolvv uq 1 <br /> gwe <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: h� <br /> C. DATE INSTALLED(MO'DAY/YEAR) /Q 517 D. TANK CAPACITY IN GALLONS: 5 to(go <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A. Q 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1aUNLEADED 3 DIESEL ❑ a AVIATIONGAS <br /> ❑ 2 PETROLEUM ❑ SO EMPTY [�!J'l PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL <br /> ❑ <br /> F-] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E] UNLEADED 5 JETFUEL <br /> 2 WASTE 02 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF F❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM I� 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK P�r1 BARE STEEL F-] 2 STAINLESS STEEL ❑ 3 FIBERGLASS [1] 4 STEEL CLAD Wt FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP <br /> (PNmaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ S UNLINED Q UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION L?-9T NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION i 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 Ej> 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 9 CONCRETE A U 7 STEEL W/COATING A I&S 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 �2 LINE TIGHTNESS TESTING ❑ 31NTER 1 A 99 OTHER <br /> MONITORING ❑ <br /> V.TANK LEAK DETECTION <br /> �❑ 1 VISUAL CHECK J?T7 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> J ° TANK TESTING E] 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATEDDATE L T ED(MO/ Y/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> Z.. SUBSTANCEREMAINING __GALLONS INERTMATERIAL7 YES ❑ NO <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!SIGNRNRE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> CmOUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LDANT = � p (� � O G / / m <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE -3 /Z <br /> 15;< <br /> FORM B(9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOROMU R/ <br />