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STATE OF CALIFORNIA �L\ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> tl UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B :mom <br /> iy <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION ❑ 7 PERMANENTLY CLOSE01AW SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ l AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: J19 S <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK H.D.s b B. MANUFACTURED BY: 'q4/AK <br /> C. DATE INSTALLED(MOIDAYNEAR) I O. TANK CAPACITY IN GALLONS: /0 <br /> II.TANK C014iENTS IFA418MARKED.COMPLETE REMC. <br /> I MOTOR VEHICLE FUEL ❑ ! OIL 8. C. ❑ IAUNLEAOED 3 DIESEL ❑ e AVIATION GAS <br /> A. a GASAHOL <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1E NLEADED ❑ 5 JETFUEL ❑ 7 METHANOL <br /> ❑ 3 CHEMI:ALPR000CT ❑ 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.11 IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: <br /> III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES AB,ANOC,ANOALLTHATAPPLIES INBOX0 <br /> A. TYPE OF F7 l"/6OU8LE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ ♦ SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL 7 FIB--R-LASS a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ S CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 UMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTA0K) ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 XY LINING ❑ A PHENOLIC LINING <br /> C.INTERIOR❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 WRAP ❑ s FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN a 99 OTHER <br /> IV.PIPING INFORMAT14 CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A(V I SUCTION A U 2 PRESSURE A U 3 GRAVITY p OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U s FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ J UONRTRIA ❑ 99 OTHER <br /> ORING <br /> V.TANK LEAK DETECTION <br /> �k F7I VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ B TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 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 I INERTMATERIAL? YES ❑ NO ❑ <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 SIGNATNRE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY s TANK# <br /> STATE I.D.# D 0 Id 101010119 � ��� <br /> PERMIT NUMBER La / PERMIT APPROVED BV/DATE PERMITEXPIF7g qN E 9/ <br /> FORM B (9.90) THIS fORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> F011=8JR <br />