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:::::s <br /> STATE OFCALIFORNIA 1; <br /> STATE WATER RESOURCES CONTROL BOARD +,„ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ,,. <br /> COMPLETE A SEPARATE FORM FORE TANK SYSTEM. D �� <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E]T7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT O a TEMPORARY TANK CLOSURE o AITPG" TTVT192 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZZ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN NVIRON MALH <br /> A. OWNEWS TANK I.D.s 11 A 4 12 W. , 7 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) ugi K4 D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-11SMARKED,COMPLETEITEM C. <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. 0 IaUNLEULAR ADED 3 DIESEL Q 8 AVIATION GAS <br /> O 2 PETROLEUM O BO EMPTY 1 PRODUCT a ib PREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADED Q 5 JET FUEL <br /> Ej 3 CHEMICALPRODUCT Q 95 UNKNOWN 2 WASTE I] 2 LEADED 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED (,joit C.A.S.0: <br /> III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXESA,B,ANDC,AND ALLTHAT A LIES INBOXDAANNDDE <br /> A. TYPE OF Q I DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM F-1 2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTEDTANK) le 99 OTHER <br /> B. TANK O I BARE STEEL 0 2 STAINLESS STEEL 0 3 FIBERGLASS E] 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE O 8 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) O 9 BRONZE O 10 GALVANIZED STEEL -6EfB5 UNKNOWN O 99 OTHER <br /> F-1 I RUBBER LINED Q 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 8 UNLINED 95 UNKNOWN O 99 OTHER <br /> LINING 111��x <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— <br /> D.CORROSION F-1 I POLYETHYLENE WRAP D 2 COATING 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION Q 91 NONE "<95 UNKNOWN 0 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( I)1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AID95 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 8 CONCRETE A U 7 STEEL W/COATING A U 8 10% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Ae 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR [ 2 LINE TIGHTNESS TESTING MDNRORING OTHER <br /> V.TANK LEAK DETECTION <br /> %lbMF-1E <br /> 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORINGQ 4 AUTOMATIC TANK GAUGING 05 GROUND8 TANK TESTING 0 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED <br /> SUBSTANCE REMAINING UGALLONS 3 WAS <br /> A INERT MATERIALTANK FILLED I7H YES O NO[-] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL O PERJUIJY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRoomn a 9roxATu <br /> -a nied <br /> LOCAL AGENCY USE ONLY THE STATE I.D. UMBER COM S OFTHE FOU NUMBER <br /> COUNTY 9 JURISDICTION 9 F LITY 9_ TANK 9 <br /> STATE I.D.#3Zy g O O d <br /> PERMIT NUMBE "'�` PERMIT APPROVED BYIDATE IT EXPIRATION DATE / A <br /> FORM B (7-91) BE ACCOMPANIEDD BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> '�` TLL{t� (v!s-5 Glcl�i e`�.��,YrG'✓�rOGte� �1Z11t�>e{�'� Ltl i I�PO� /`� <br />