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w � <br /> �♦� �i <br /> STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 54, 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT E�] S TEMPORARY TANK CLOSURE a TANK REMOVED <br /> DEAOR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> B. MANUFACTURED BY: <br /> A. OWNER'S TANK I.D.# <br /> C. E INSTALLED D. TANK CAPACITY IN GALLONS: <br /> DAT <br /> ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. IA REGULAR 3 DIESEL O S AVIATIONGAS <br /> A r1 MOTOR VEHICLE FUEL 4 OIL EL IFp�I C. (!_y UNLEADED PREMIUM q GASOHOL 7 METHANOL <br /> 2 PETROLEUM F 00 EMPTY LPL I PRODUCT UNLEADED Q 5 JET FUEL <br /> 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED 9D OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D, IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.9,AND C.AND ALLTHAT APPLIESIN BOX D ANDS <br /> 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 1:71 95 UNKNOWN <br /> A. TYPE OF O 99 OTHER <br /> SYSTEM ® 2 SINGLE WALL 4 SECONDARY CONTAINMENT NAULTEDTANp <br /> 1 BARE STEEL 2 STAINLESS STEEL 0 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC <br /> B. TANK 9 POLYVINYL CHLORIDE � 7 ALUMINUM S 10D% METHANOL COMPATIBLE W/FRP <br /> MATERIAL O 5 CONCRETE <br /> (Primary Tmk) O 9 BRONZE E] 10 GALVANIZED STEEL E] 95 UNKNOWN O W OTHER <br /> O I RUBBER LINED O 2 ALKYD LINING E] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O S UNLINED �z 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— <br /> D.CORROSION F—] 1 POLYETHYLENE WRAP O 2 COATING 0 3 VINYL WRAP ED 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E�] 5 CATHODIC PROTECTION O 91 NIXIE tK 95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) -Air 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 I SUCTION AeJ52 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTON A 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 I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION I AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING Q MONROR0I3Q 99 OTHER <br /> V.TANK LEAK DETECTIONqmL <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING E::] 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O S TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 0 95 UNKNOWN Q 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYtYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUB STA NCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,/S TRUE AND CORRECT <br /> APPLICANTS NAME _ DATE <br /> (PRINTED8 SIGNP , <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# � � ZFACILITY# TANK# <br /> STATE I.D.# a7 SkC /XIJ� L� (L(L I (O <br /> PERMITNUMBER 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 /> FILE THIS FORM WITH TMc LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMS (12-91) FOR001113-R6 <br />