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STATE OF CAUFORNA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> (/ ; <br /> COMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATK)N ❑ RMANE LV OSEO ITE - <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE �8 TEANK RE OV <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6/57 / <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.0.0 B. MANUFACTURED BN <br /> C. DATE INSTALLED(MO/DAV/YEAR) k-f D. TANK CAPACITY IN GAL <br /> ILTANKCONTENTS IFA-1 ISMARKEO.COMPL ITEMC. <br /> REGULAR <br /> A ❑ 1 MOTOR VEHICLE FUEL 6 OIL S. C. ❑ 1AUNLEA ED S DIEBEL ❑ 8 AVIATIONGAS <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PR OUCT ❑ 10 PREMIUM A GASAHOL ❑ 7 METHANOL <br /> ❑ 7 CHEMICAL PRODUCT ❑ 95 UNKNOWNTEUNLEADED iliET L <br /> ❑ 2 LEADED99 OTHER DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Q C.A.S.8: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 0 SINGLE WALL WITH EXTERIOR LINER I❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 7 FIBERGLASS l STEEL CUD W/FIBERGLASS REINFORCEO PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UN194OWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 0 EPDXY LINING ❑ 6 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND ORUIFUNERGROUND.BOTHIFAPPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U S GRAVITY A U 99 OTHER <br /> 1 B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 2 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 S POLYVINYL CHLORIOE(PVC)A U a FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> / D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE T GHTNESS TESTING ❑ ) MONRORNG ❑ 9v OTHER <br /> �( V.TANK LEAK DETECTION <br /> l"'NNN ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 7 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONRORING <br /> I'\U\ ❑ 8 TANK TESTING ❑ 7 INTERSTMALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 7.WAS TANK FILLED WITH YES ❑ ❑ <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? 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 /> (MNr 0A SK•NATUBEI — n d <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW (�— <br /> COUNTY x JURISDICTION s FACILITY x TANK <br /> STATE I.D.# 2 F-F77 loloU <br /> PERMIT NUMBER PERMIT APPROVED SYIDATE I PERMIT EXPIRATIONDAT <br /> J <br /> FORMS (9-9M THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> WROO]ABIY <br /> tf•• <br />