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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD E <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> 1 ^ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED , <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z Z-5 6 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.• v /i B. MANUFACTURED BY: v /� <br /> C. DATE INSTALLED(MODAYNEAR) C,.K , D. TANK CAPACITY IN GALLONS: G/ <br /> ILTANKCONTENTS IFA-11S MARKEOCOMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL4 OIL B. O. 1aUN EADEO REGULAR 3 DIESEL 0 g AVIATION GAS <br /> 2 PETROLEUM 0 80 EMPTY �)_PflOWCT 0 lb PREMIUM 4 GASAHOL 0 7 METHANOL <br /> 0 FUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 0 2 WASTE UNLEADED <br /> 5 JETHER <br /> 99 OTHER (DESCRIBE IN ITEM 0. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ..-�, C.A.S,#; 'y <br /> III. TANK CONSTRUCTION MARKONEITEMONLYINBOXESA,B,ANDC,ANDALLTHATAPPLIESINBOXDANDE <br /> A. TYPE OF O 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTEDTANK) Fp-1% OTHER <br /> S. TANK 0 1 BARE STEEL 0 2 STAINLESS STEEL 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE O 6 POLYVINYL CHLORIDE7 ALUMINUM 0 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 0 B BRONZE 0 10 GALVANIZED STEEL 95 UNKNOWN 0 99 OTHER <br /> 0 1 RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING 0 6 UNLINED 95 UNKNOWN 0 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION O 1 POLYETHYLENE WRAP 0 2 COATING 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 0 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 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 AS;--b5 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 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A<11:ii UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 01 AUTOMATIC LINE LEAK DETECTOfl0 2 LINE TIGHTNESS TESTING 0 <br /> INTERSTITIAL <br /> 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING <br /> 0 6 TANK TESTING 0 7 INTERSTITIAL MONITORING 0 91 NONE UNKNOWN 0 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 0 NOu <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 <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 61GNAIDREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# F <br /> STATE I.D.# <br /> PE RM IT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE �� I <br /> Z <br /> THIS FORM MUST BE ACCOMPANIED BY A PERW APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FORMS (12-91) <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 1 <br /> r FOB &pj <br />