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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR E 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 6 TANK REMOVED <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: (1 S, Air' or !.J ! llk . <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: LL <br /> C. DATE INSTALLED(MO/DAWYEAR) D. TANK CAPACITY IN GALLONS: C Q <br /> II.TANK CO NTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. 0 to REGULAR ED 3 DIESEL 0 6 AVIATIONGAS <br /> 2 PETROLEUM 0 60 EMPTY 1 PRODUCT 0 1b PREMIUM ����IIII 4 GASAHOL O 7 METHANOL <br /> 3 C14EMICALPFIODUCT 0 95 UNKNOWN 0 2 WASTE ❑ UNLEADED 99 OTHER (DESCRIBEIN ITEM D. BELOW) <br /> 2 LEADED u <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 D AND <br /> A. TYPE OF 0 1 UBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 LE WALL 0 4 SECONDARY CONTAINMENT (VAULTEDTANK) 0 89 OTHER <br /> B. TANK Lbrl BARE STEEL 0 2 STAINLESS STEEL 0 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE O 6 POLYVINYL CHLORIDE 0 7 ALUMINUM O B 1009 METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 09 BRONZE 0 10!l��GAALL'VANIZED STEEL 0 95 UNKNOWN 0 09 OTHER <br /> O / RUBBER LINED 0 Z D LINING O 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING �,����,//88/UNLINED 0 95 UNKNOWN 0 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 1(X0%METHANOL? YES NO— <br /> D.CORROSION <br /> O_D.CORROSK)N 0 1 POLYETHYLENE WRAP 0 2 ATING 0 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODICPROTECTION 91 NONE 0 95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED MAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 S ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% 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 DETECTIONE LEAK 2 LINE TIGHTNESS TESTING 3 <br /> 0 1 AUTOMATIC LINLAK D0 MONRORING 099 OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING 0 5 GROUNDWATER MONITORING <br /> (� 6 TANK TESTING O 7 INTERSTITIAL MONITORING 0 91 NONE 0 95 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 <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES 0 NOO <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 a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# 1Y6L,E/.)7y <br /> STATE I.D.# <br /> PERMIT NUMBER PMIT APPROVED BV/DATE PERMIT EXPIRAT N ATE <br /> ERao <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 /> (//,u Fdia0346A� ) <br />