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- a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON$LTE <br /> ONE ITEM a 2 INTERIM PERMIT � 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED IC / <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1360 q p vi <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.* -T B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) 0 S D. TANK CAPACITY IN GALLONS: Ww <br /> ILTANKCONTENTS IFA-11SMARKED,COMPLETEITEMC. n <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. UNLEADED 3 DIESEL O 8 AVIATION GAS <br /> O 2 PETROLEUM O BO EMPTY 1 PRODUCT 1b PREMIUM LULJ 4 GASAHOL 7 METHANOL <br /> UNLEADED Q 5 JETFUEL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE 0 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF O I DOUBLE WALL F-1 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEMINGLE WALL E::] 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK O I BARESTEEL 0 2 STAINLESS STEEL O 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL D 5 CONCRETE O e POLYVINYL CHLORIDE O 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 0 9 BRONZE O 10 GALVANVED STEEL � UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING F7 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED �-0 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION F-1 I POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION O 91 NONE �.96-UNKNOWN 99 OTHER <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 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 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 6 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 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTIONOMATIC LINE LEAK DETECTOR J�TIGHTNESS TESTING O 31NTERST 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> J 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING E] 4 AUTOMATIC TANK GAUGING 6 GROUND WATER MONITORING <br /> 8 T NK TESTING FZVAwVfsTlTIAL MONITORING E 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 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 B SIGNRNRE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# MC,000J11-3 <br /> STATE I.D.# 20 1 1 11 ILA Ig 6 Z <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 3-%-- <br /> 1-3 JV- <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> �j�J/ FOR09NB Ra <br />