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STATE OFCAUFORNA ^`� �� <br /> STATE WATER RESOURCES CONTROL BOARD ;° o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B m� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. • °'1'•0^"'' <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: U 6 p t,755 p vi <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN <br /> A OWNER'S TANK I.D.• -z B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYNFAR) 6 D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-11SMARKED.COMPLETEITEM C. <br /> A. 7(A.1)13 <br /> TOR VEH;ENTER <br /> UEL ❑ 4 OIL 8. EGULAR <br /> IESEL <br /> ROLEUM Q 80 EMPTY 1 PRODl11 UNLEADED 4 GGASAHOL S AVIATIONGAS <br /> ❑ lbP ELMIUM 5 JETfUEL ❑ 7 METHANOL <br /> EMICAL PT O % UNKNOWN ❑ 2 WASTE 2 LEADED❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW)D. T MARKENAME OFSUBSTANCE STORED <br /> C.A.S.m: <br /> III. TANK CONSTRUCTION MARKONEITEMONLYINBOXESA.B.ANDC,ANDALLTHATAPPLIESINBOXD <br /> A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> ❑ 95 UNKNOWN <br /> SYSTEM SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 0o OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FlBEROI sa REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM = 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL � 'Y UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> LINING ❑ 5 CLAM LINING ❑ 8 UNLINED B-a&-UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO_ <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ <br /> PROTECTION O 5 CATHODIC PROTECTION ❑ 91 NONE I-����3 VINYL WRAP <br /> ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> % OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION p PRESSURE A U 3 GRAVITY ! <br /> A U 99 OTHER <br /> B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH <br /> A U % UNKNOWN p U 99 OTHER <br /> C. MATERIAL AND A U 1 BAREST 4 U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE VC <br /> CORROSION A U 5 ALUMINUMN )A U 4 FIBERGLASS PIPE <br /> A U S CONCRETE A U 7 STEEL W/COATING A U 8 100% M <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ETHANOL COMPATIBLE W/FRP <br /> A U % UNKNOWN A U N OTHER <br /> D. LEAK DETECTKINOMATIO LNE LEAK DETECTOp TIOHTNESS TESTING O <br /> V.TANK LEAK DETECTION MONROgIKc ❑ oT ER <br /> LEIVISU=CHECKE�2NTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> T NSTITIAL MONITORING ❑ 9/ NONE <br /> ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED GATE LAST USED(MOIDAY/YR) 2 ESTIMATED OUANTTY OF <br /> SUBSTANCE REMAINING 3.WAS TANKFILLED WITH YES ❑ NO[] <br /> 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 <br /> (pmN Eo&="TURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# / TANK# 1 I <br /> STATE I.D.# nj <br /> / M�ppc,j <br /> PERMIT NUMBER PERMITAPPROVED SY/DATE I I <br /> PERMIT EXPIRATION DATE <br /> FORM B (4901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> I <br /> RO WSM 1 <br />