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F40u9: C <br /> STATE OF CALIFORNIA a� '" 's, <br /> STATE WATER RESOURCES CONTROL BOARD. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B P� "�� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM "�� <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEMO 2 INTERIM PERMIT Q 4 AMENDED PERMIT S TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.i B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) O. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> A, 1 MOTOR VEHICLE FUEL 4 OIL B.y ,J C. laUNL ULAR EO O 3 DIESEL O 6 AVIATION GAS <br /> PETROLEUM 0 80 EMPTY I�fdt PRODUCT O 1bULEIUM 5 JET FUEL <br /> ❑ 7METHANOL <br /> 0 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A S. <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D ANDS <br /> A. TYPE OF D 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM -{ � 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANIQ 99 OTHER <br /> B. TANKSfid 1 BARE STEEL 2 STAINLESS STEEL F-13 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL LFL-Jl_ 5 CONCRETE F-1 a POLYVINYL CHLORIDE F-] 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PHmwyTmk) 0 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-� 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING JCL 6 UNLINED 95 UNKNOWN O 99 OTHER <br /> LINING X -. <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP [::] 2 COATING F-1 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION K91 NONE D95 UNKNOWN Q 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION e <br /> 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNW40WN A U 99 OTHER <br /> C. MATERIAL AND Ato BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPAT18LE 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 DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 9 99 OTHER <br /> MONROflING 0 <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING F-1 5 GROUND WATER MONITORING <br /> e TANK TESTING = 7 INTERSTITIAL MONITORING F-1 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF <br /> TANCE REMAINING GALLO3.WAS TANK FILLED WITH YES 0 NOO <br /> SUBSNS INERT MATERIAL 7 <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&SIGNAT FIE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / D <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATON DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDE GND STORAGE TANK REGULATIONS <br /> FORMS (12-911 1fl�' /M,/1 FONORM&R6 <br /> s/ 5 5-3 -- �� 9`t/v <br />