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STATE OF CALIFORNA <br /> STATE WATER RESOURCES CONTROL BOARD I <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ° <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM Imo' 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: J s <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS--SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.% B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYKEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS FA-11SMARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. aUNLEULAA <br /> AD D F7 3 DIESEL 6 AVIATIONGAS <br /> �2 PETROLEUM 80 EMPTY �.1 PRODUCT tb PREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADED O 5 JETFUEL <br /> O 3 CHEMICAL PRODUCT 95 UNKNOWN 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. <br /> III. TANK CONSTRUCTION MARK O\E ITEM ONLY IN BOXES A,S.AND C.AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK O i BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE a POLYVINYL CHLORIDE 7 ALUMINUM F-18 100% METHANOL COMPATIBLE W/FRP <br /> (PrImaryTank) 9 BRONZE 10 GALVANIZED STEEL O 96 UNKNOWN 0 99 OTHER <br /> 0 1 RUBBER LINED O ALKYD LINING 3 EPDXY LINING F-14 PHENOLIC LINING <br /> C.INTERIOR O 6 GLASS LINING 6 NLINED <br /> LINING 96 UNKNOWN O 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COA NG F7 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 91 NON O95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U\ <br /> UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURX A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE LL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U i BARE STEEL A U2 STAINLESS TEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 8 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 PR TECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE IGHTNESS TESTING 3INTERD" 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION O 3 VADOZE MO ITORING 4 AUTOMATIC TANK GAUGINGF–] 5 GROUNDWATER MONITORING <br /> 0 6 TANK TESTING 0 7 INTERSTITIAL MONITORING O 91 NONE 0 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.EST TED TE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITYOF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES O 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 8 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.# Q <br /> PER TN BEPje <br /> PERMIT AP OVEDB PERMIT EXPIR T DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> 461-FORM <br />