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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z 2-f 2Z S? Q <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# o B. MANUFACTURED BY: r l�1- S <br /> C. DATE INSTALLED(MO/DAY/YEAR) 465 D. TANK CAPACITY IN GALLOONS: 70 5 Qd <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEMC. <br /> A. 1 MOTOR VEHICLE FUEL O 4 OIL B. C. �Q 1aUN GiULAR <br /> EA ED O 3 DIESEL O 6 AVIATIONGAS <br /> 2 PETROLEUM O SO EMPTY 1 PRODUCT Irl "�NLPREMIUM <br /> 0 5 GASAHOL JETFUL 7 METHANOL <br /> Q 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C,AND ALL THAT APPLIES IN BOX D ANDS <br /> A. TYPE OF F-1I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM �[ofj 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER <br /> B. TANK L1 ' 'ARE STEEL O 2 STAINLESS STEEL F-1 3 FIBERGLASS O 4 STEELCLAO W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL a 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) D 9 BRONZE O 10 GALVANIZED STEEL �UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR [71 5 GLASS LINING 6 UNLINED 95 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 O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION O 91 NONEUNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOU IPM ENT INSTALLED(YEAR) <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 A U 99 OTHER <br /> B. CONSTRUCTION A(!n 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 RARE 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 0UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 99 OTHER <br /> MONITORING D <br /> V.TANK LEAK DETECTION <br /> 1-1 F1 VISUAL CHECK 2 INVENTORY RECONCILIATION 0 3 VAD07E MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 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 I INERT MATERIAL 7 YES O NO O <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 /> (PRINTEDa BIGNATU EI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# 6 oI I I b 10 d <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 /> i iJ Rs <br />