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of <br /> ♦�sC C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD sy��, aa's <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM "��,, <br /> MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLO SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ni, V I� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.0 B. MANUFACTURED BY: <br /> 02 <br /> C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 0 4 OIL 8. C. taUNLEA ED+H 3 DIESEL O 8 AVIATION GAS <br /> O 2 PETROLEUM O 80 EMPTY 1 PRODUCT 1b PREMIUM 4 GASAHOL O 7 METHANOL <br /> NUEADED <br /> L <br /> 3 CHEMICALPRODUCT 0 95 UNKNOWN 2 WASTE 0 2 LEADED O 99 JOTHER (ESCRIBE IN ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: <br /> III. TANK CONSTRUCTION MARK ONE REM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF F-1 1 DOUBLE WALL F-1 3 SINGLE WALL WITH EXTERIOR LINER O 85 UNKNOWN <br /> SYSTEM LI ypyR2 SINGLE WALL Q 4 SECONDARY CONTAINMENT NAULTEDTANK) [] 99 OTHER <br /> B. TANK f1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE F-� 8 POLYVINYL CHLORIDE O 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP <br /> (Pdtn"Tmk) 0 9 BRONZE a 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING O 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED Dc95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.CORROSION F-� 1 POLYETHYLENE WRAP F-] 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F7 5 CATHODIC PROTECTION Q 91 NONE W6 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVE UNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A(:U-�b 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 1 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 6 CONCRETE A U 7 ST LW/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR O2 LINE TIGHTNESS TESTING Q MONRORIN1 O 99 OTHER <br /> V.TANK LEAK DETECLLLTTII�ON <br /> ❑ 1 VISUAL CHECK YY 11 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> O 6 TANK TESTING `F- 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNA) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES E-] 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 6 SIGNATUM <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /O <br /> COUNTY# JURISDICTION# FACILITY If TANK# <br /> STATE I.D.# ® �1 L1�l d <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE 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 STn4AGE TANK REGULATIONS <br /> FORM B (12-91) FOR000I&R6 <br />