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a�[9 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� "° <br /> C�(�iO�N,�.P <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED; PV6 5 CS O✓1 p <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# M B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) V 9 D. TANK CAPACITY IN GALLONS: <br /> IL TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A. <br /> MOTOR VEHICLE FUEL E 4 OILB. C. le REGU R 0 3 DIESEL 6 AVIATIONGAS <br /> ❑ 2 PETROLEUM O SO EMPTY 1 PRODUCT O 1b PREMIUM O 4 GASAHOL Ej 7 METHANOL <br /> UNLEADED <br /> L <br /> 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE 2 LEADEDO 99 JOTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.o: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF �O 11 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER Q 95 UNKNOWN <br /> I! <br /> SYSTEM 2rl2 INGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK E?r" BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEELCLD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM E] 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrlmaryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL O 95 UNKNOWN 0 99 OTHER <br /> F--] i RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 6 UNLINED O 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 CO G F-] 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTK)N 1 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 ABOVG DOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION LOU PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION U 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 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 SMELWICOATING A U 6 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION p U e GALV IZED STEEL A U 10 CATHODICPR ECTION UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR Ff2 LINE TIGHTNESS TESTING B <br /> MON90flING D 99 OTHER <br /> V.TANK LEAK DETECTION <br /> CHECK Z2 INVENTORY RECONCILIATION 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> e TANK TESTING 0 7 INTERSTITIAL MONITORING 0 91 NONE 0 95 UNKNOWN O 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 <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES NOO <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 /> (PRIMED a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# ✓ICAICA5 <br /> STATE I.D.# ® I 1 111S sl 6 611 <br /> JJ� <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> 6 0?3- <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> L/ // FOROtOa B.RS <br />