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•66.A,. o <br /> STATE OF CALIFORNIA ^. .. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B w�� �e <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> �..,,o'� <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION F—] 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED /� <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: z 52-1;-- Cl <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOrDAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-11SMARKED,OOMPLETE ITEM C. <br /> A / MOTOR VEHICLE FUEL 0 4 OIL I" C. Q taUNLEULAR <br /> ADED `n�j 3 DIESEL O 6 AVIATION GAS <br /> O 2 PETROLEUM O 80 EMPTY 1 PRODUCT O 1b PREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADED O 5 JET FUEL <br /> 3 CHEMICAL PRODUCT Q 95 UNKNOWN O 2 WASTE get LEADED 0 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 O I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E::] 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK F_� 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD WI FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE F-1 8 POLYVINYL CHLORIDE O 7 ALUMINUM O B 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTm*) Q 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O w OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING F-1 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION F-1 1 POLYETHYLENE WRAP O 2 COATING r—] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F_� 5 CATHODIC PROTECTIONF-1 91 NONE O 95 UNKNOWN O 99 OTHER <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 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 8 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION El 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTINGO 31NTERST u D 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> I VISUAL CHECK Q 2 INVENTORY RECONCILIATION F-1 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING F_� 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? <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 31"ATURMI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD.# 7741yf12s <br /> PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM 6 (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> J( <br />