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...m. *two 'FhOJR:9 CO <br /> STATE OF CALIFORNIA �` '"; <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B rr <br /> •`-tai <br /> COMPLETE A SEPARATE FORM Fo EACH TANK SYSTEM <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT It 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 3/ j <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A OWNER'S TANK I.D.# S/ _ Q B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> 11.TAN CONTENTS IFA-i IS MARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 0• 1aUNLEA REGULAR <br /> 3 DIESEL ❑ 6 AVIATIONGAS <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY d PRODUCT ❑ th PREMIUM 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADED ❑ 5 JETFUEL <br /> ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 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 CONSTRU TION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF / DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP <br /> (PdmmyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 0 OTHER <br /> ❑�1 RUBBER LINED ❑ 2 ALKYD LINING E:] 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.IN ' GLASS LINING ❑ 6 UNLINED ❑ B5 UNKNOWN ❑ 99 OTHER <br /> LININGNING u <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN E2'�99 OTHER T <br /> 4, <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(NEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U / SINGLE WALL A 0 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> it C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Z 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MOTERSTITIAL <br /> NITORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> F-1 1 VISUAL CHECK F12 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING EZ7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH YES ❑ NO❑ <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <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 0 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY It JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# 541 allC 111 116 Ilo I iI,- <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ' <br /> FORM B 02-91) // <br /> FILE THIS FORM WITC LOCAL AGENCY IMPLEMENTING THE UNDERGROUND 77 GE TANK REGULATIONS <br /> � FOROONBR6 <br />