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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> V <br /> j j UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ',•° <br /> `. <br /> COMPLETE A SEPARATE FORM FO ACH TANK SYSTEM. �����,• <br /> MARK ONLY O 1 NEW PERMIT 1--� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a TANK REMOVED O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D. B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MONAY/YEAR) U D. TANK CAPACITY IN GALLONS: V <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1aUNLEADED 4 GASAHOL 6 AVIATION GAS <br /> O 2 PETROLEUM O EMPTY Ei 1 PRODUCT III PREMUM O 5 EL El7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE O 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.R <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF UBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM EW2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANX) O 99 OTHER <br /> B. TANK = 1 BARE STEEL 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE 6 POLYVINYL CHLORIDEn 7 y.UMINUM B 100% METHANOL COMPATIBLE W/FRP <br /> (PHmuyTmk) 9 BRONZE 0 10 GALVANIZED STEEL 5 UKXXXNNNNOWN O 99 OTHER <br /> 1 RUBBER LINED O 2 ALKYD LINING ❑ UUUUNKNOWN <br /> 0 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING F-1 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO- <br /> D.CORROSION D 1 POLYETHYLENE WRAP O 2 COATING3 L WRAPO d FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN O 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 A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> N 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 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/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 O 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING ❑ 3 <br /> MONITORING D 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 + 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> N6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 99 OTHER <br /> A.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANKFILLEDWITH VES ONO <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 /> IPRINTED4$IGNATUREI -z 3 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NU G Gam' r <br /> COUNTY x JURISDICTION x FACILITY x K x <br /> S ATE I.D.# F341 = p <br /> PERMIT NU ER e—j1 3 PERMITAPPROVED BY/DATE EXPIRATION DA <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORM B (12-91) <br /> FILE THIS FORM WITH THE I LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REI;ULATIONS <br /> FOR5mI3Re <br /> tiu,/ <br />