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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY Q NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE REM INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED Q Z <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -r c <br /> ll <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.8 — S. MANUFACTURED BY: N <br /> C. DATE INSTALLED(MO'DAYNEAR) ' D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL O 4 OIL B. C. 1aUNL U LAR ED 3 DIESEL O 6 AVIATION GAS <br /> O 2 PETROLEUM 80 EMPTY 1 PRODUCT O 1b PREMIUM 4 GASAHOL O 7 METHANOL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE E] 2 LEAUNLEADED L <br /> Q 99 JOTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.a: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLES IN BOX D AND <br /> A. TYPE OF O I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O BS UNKNOWN <br /> SYSTEM I�4 [ SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER <br /> B. TANK El 1 BARE STEEL ❑ 2 STAINLESS STEEL [--� 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE F-1 a POLYVINYL CHLORIDE O 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrNmwyTAOk) ❑ 9 BRONZE O 10 GALVANIZED STEEL UNKNOWN O 99 OTHER <br /> 0 1 RUBBER LINED 0 2 ALKYD LINING F--] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED �,85 UNKNOWN 99 OTHER <br /> LINING rY <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION Q 91 NONE Ewlp <br /> 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 ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION p V PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Aru9 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION �TOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING O3 <br /> MOTERSTITIAL N80mNG 099 OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 0 6 TANK TESTING F-] 7 INTERSTITIAL MONITORING O 91 NONE O 96 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 INERT MATERIAL YES O 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 DATE <br /> IPRINTEO a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# fACTfFT71 f TANK# <br /> STATE I.D.# [KRI zf3 c S Lv I z Ilo <br /> PERMIT NUMBER PER MIT APPROVED BY/DATE PERMIT EXPIRATION DATE �� y <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> - <br /> FORM B (12-91) <br /> FOROON&1 <br /> v `� <br />