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STATE OF CAIJPoRNA <br /> STATE WATER RESOURCES CONTROL BOARD4. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR ANK SYSTEM "'•°""''. <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 15-13-5- , r✓t kL �l�G <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# O B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: �T CD <br /> 41 <br /> If.TANK C NTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 04 OIL 9, C El to NLEAD S 3 DIESEL O 9 AVIATION GAS <br /> 2 PETROLEUM e0 EMPTY 7 PRODUCT 1b PREMIUM B 4 GASA40L � 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT E 95 UNKNOWN 2 WASTE 2 L DD <br /> 911 OTHER (SCRIBE IN REM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTIQN MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OFDOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 LE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL O 3 FIBERGLASS a 4 STEEL CUD WI FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE E�] 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PdmvyTank) 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN 99 OTHER <br /> 0 1 RUBBER LINED 0 KYO LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 8 UNLINED <br /> LINING 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP 0 2 COATING 3 WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTIONE:] 91 NONE 95 UNKNOWN Q 99 OTHER - <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTIA U PRESS A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WA A U 2 DOUBLE WALL A U 3 LINED TRENCH <br /> A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A USTEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PI <br /> CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATING A U 8 100% M NOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 0TH <br /> D. LEAK DETECTION Q 7 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 031 ONROfl G OTHER /OL <br /> V.TANK LEAK DETECTION <br /> ❑ 7 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING a 5 GROUNDWATER MONITORING <br /> 8 TANK TESTING 0 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 9a OTHER <br /> A.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(M Y/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES O 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 <br /> 4DATE <br /> IPNNTEG lIGN4TURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LDA ® 6 <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR09MSAA /v—/) <br />