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SPATE OF CALIFORNIA � <o <br /> STATE WATER RESOURCES CONTROL BOARD ty 40 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "mom ae <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �""°""'� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D/ <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5­5- fe <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK LD.# , S. MANUFACTURED BY: <br /> O. DATE INSTALLED(MOIDAWYEAR) D. TANK CAPACITY IN GALLONS: V <br /> If.TANK CONTENTS IFA•11SMARKED,COMPLETE ITEM C. <br /> A ❑ f MOTOR VEHICLE FUEL ❑ s OIL B. C ❑ IAUNGLEADED 3 DIESEL ❑ 8 AVIATIONGAS <br /> ❑ 2 PETROLEUM ❑ 90 EMPTY ❑ 1 PRODUCTIb PREMIUM A GASA40L 7 METHANOL <br /> ❑ ❑ <br /> ❑ 3 CHEMICAL PRODUCT E:] 96 JET FUEL <br /> 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 8 959 p7OlER (DESCRIBE IN ITEM 0. BELOW) <br /> D. IF(A./)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX <br /> I DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER <br /> A. TYPE OF ❑ ❑ 96 UNKNOWN <br /> SYSTEM e/2 BINDLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ { STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrlmvyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER <br /> 711 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING <br /> C.INTERIOR F-15 GLASS LINING ❑ 8 UNLINED � <br /> LINING UNKNOWN C-] 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO- <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VWYL WRAP E:] { FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION C:] 91 NONE UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE ANI SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 9S 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANRED STEEL A U 10 CATHODIC PROTECTION A U 96 UNKNOWN A U 99 OTHER <br /> 0. LEAK DETECTION ❑ I AUTOMATICLIE LEAK DETECTOR ❑ 2 LI NE TIGHTNESS TE NG ❑ 3I 99 07fMER <br /> I ONRORIN(O ❑ <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ® 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 6 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MGKOAYAYR) 2.ESTIMATE000ANTITYOF 3.WAS TANK FILLED WITH <br /> SUB STAN CE REMAINING GALLONS I INERTMATERIAL7 YES ❑ 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 <br /> )PRINTED ASI9NANNEI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBERS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.O.# mi 10101/ 1o A 0 L91 oll o / <br /> PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> F011001LPS <br />