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1 1 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD t" <br /> UNDERGROUND STORAGE TANK PERMIT AP <br /> PLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR H TANK SYSTEM <br /> �..,. ,• <br /> MARK ONLY 1 NEW PERMIT c:3 5 RENEWAL PERMIT 5 CHANGE OF INFORMATION F7 7/ RMANENTL I <br /> ONE ITEM ❑ 2 INTERIM PERMIT Q a AMENDED PERMIT ❑ 9 TEMPORARY TANK CLOSURE ro' 8 TANK R Q 0 LOSER SITE { <br /> ucU <br /> DBA OR FACILITY NAME WHERE TANK-IS INSTALLED: <br /> 1. TANK DESCRIPTION C MPLETE ALL rrEMS— 1PECI Y IF UNKNOWN I <br /> I. A. OWNERS TANK L D_• 8. MANUFACTURED 8Y: uyC <br /> C. DATE INSTALLED(MODAYNEAR) <br /> D. TANK CAPACMf IN GALL <br /> F <br /> 11.TANK C ENTS IF 4 I IS MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B C. ❑ I;AEG R S DIESEL <br /> e AVWTiCNGAS <br /> ❑ 2 PETROLEUM ❑ gp EMPTY t PROOUCT 4 PAEi}R!M A GASAHOL <br /> OFO <br /> UNLEA6, JET ❑ 7 METHANOL <br /> ❑ ] CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADEt). 99 OTHER {OrSCP IN <br /> REM 0. 9£IQYr} <br /> 0. IF[A.1)IS NOT.4AAKGO, ENTER NAME OF SUBSTANCE STORED C.A. <br /> f: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY INSOXESA.S.AND C.AND ALL THAT APPLIES IN80XO <br /> TTYPE OF ❑ I BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN i <br /> SYSTEM Er 2 SINGLE WALL a SECONDARY CONTAINMENT (VAULTED T" 99 OTHER <br /> B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 2 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ S CONCRETE ❑ s POLYVINYL CHLORIDE p 7 INUM ❑ 8 100% METHANOL COMPAT:HLE WPFRP <br /> {FrimuyTaek) ❑ 4 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LiN£0 ❑ 2 AtKYO LINING ❑:�3 — XY LINING ❑ 4 PHENOLIC LINING <br /> C.l LININGR ❑ 5 GLASS LIVING ❑ a UNLINED 95 UNKNOWN ❑ 94 OTHER <br /> I IS LINING MATERIAL COMPATIBLE WITH t00% METHANOL? YES, NO_ <br /> 0.CORROSION ❑ 1 POLYEn'IYME E WRAP ❑ 2 COATING ❑ 9 VINYL WRAP ❑ t FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ S CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHEA <br /> i- <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGSOUNDOR U IFUN>rEAGAOUND.BOTHIFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 9 GRAVITY A V 99 OTHER <br /> B. CONSTRUCTION A U t SINGLE WALL A V 2 OCUBLE WALL A U a LINED TAENCH A U 95 UNKNOWN A V 99 OTHER <br /> C. MATERIAL AND A U t BARE STEEL A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC)A U a F18ERGLASS PIPE <br /> CORROSION A U i ALUMINUM A U S CONCRETE A U 7 STEELVWCOATWG A U B 100% METHANOL COMPATIBLE W/FRP 1 <br /> PROTECTION A U 9 GALVANrZED STEEP. A U 10 CATHCOSCPROTECTION A U 95 UNI4YOWN A U 99 OTHER <br /> 0. LEAK DETECTION p 1 AUTCMAT:C LINE LEAK DETECTOR I LINE TIGHTNESS TESTING7 K IAL <br /> 4CNITORING C:] 49 OTHER <br /> a. V.TANK LEAK DEFECTION I <br /> T <br /> E1C3 <br /> VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 9 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING CD GRCUNO WA i mA MCNiTCAING <br /> TANK TESTING ❑ 7 INTERSTITIAL MONrTORING C] 9t NONE ❑ 95 UNKNOWN <br /> ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED PATE LAST USED{MOICAY/YR) 2.ESTIMATEO CUANTRY OF 3 WAS TANK FILLED WITH <br /> SUBSTANCE REMAINIlqCAlLONS INERT.uATERIAL? YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND O 7NE BEST OF MY KNOWLEAGE7S AUE AND F�ECT <br /> f; APPUCANrsNAME - I <br /> ImurH01+socrutvap � / Oa TE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOS�D OFTHE FOUR NUMBERS BELOW !�✓ <br /> �f COUNTY# JURISOICTK7N I FACILITY A TANK: <br /> �(.j F� <br /> STATE I.Dl I I <br /> PERMIT NUMBER doPERMIT APPROVED BYJtATE P0I717 EXP1RATiON DATE <br /> f <br /> I <br /> I; <br /> FORM B 19 qQ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATIO FORD A,UNLESS A CURRENT FORM A HAS BE�FIL-co. <br /> - >:aaom+aw <br />