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OR <br /> STATE OFCAUFORNIASTATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. (] 7 PERMANENTLY CLOSED ON SITE <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O B TANK REMOVED S <br /> MARK ONLY O I NEW PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE <br /> ONE ITEM 2 INTERIM PERMIT <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN al <br /> B MANUFACTURED BV: WC\ <br /> A.OWNERS TANK I.D.>< of D. TANK CAPACITY IN GALLONS: V <br /> C. DATE INSTALLEu WM DA --l) <br /> IFA-11SMARKED.COMPLETE ITEM C. C ❑ taPNGEULAEO 3 DIESEL 6 AVIATKNJGAS <br /> II.TANKCONT <br /> 4 OIL B. 4 GASAHOL 7 METHANOL <br /> A 1 MOTOR VEHICLE FUEL 1 PRODUCT 0 1b PREMIUM UNLEADED ❑ 5 JET FUEL <br /> 0 2 PETROLEUM 80 EMPTY 2 WASTE 0 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> O 3 CHEMICALPRODUCT 0 95 UNKNOWN Q <br /> C.A.S.#: <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED <br /> rMATERIAL <br /> TANK CONSTRUCTION MARK ONE ITEM ONLY IN 3 &NGS B.AWALL WITH AND ALLIORT APPLIES INBOX DO 96 UNKNOWN <br /> OF O 1 DOUBLE WALL 99 OTHER <br /> EM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) Q <br /> 1 BARE STEEL 2 STAINLESS STEEL E] 3 FIBERGLASS O 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> K Q 8 100% METHANOL COMPATIBLE WIFRP <br /> 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM <br /> 10 CiALVANI2ED STEEL 95 UNKNOWN B9 OTHER <br /> y Tank) O a BRONZE <br /> 1 RUBBER LINED 2 ALKYD LINING � 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 6 GLASS LINING O 6 UNLINED 2rUNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO_ <br /> O 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION6 UNKNOWN 99 OTHER <br /> PROTECTION � 5 CATHODIC PROTECTION = 91 NONE <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 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 I 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 WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(j',0 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING L MONITORING3 INTERSTITIAL Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> Q 1 VISUAL CHECK 2 INVENTORY RECONCILIATION Q 3 VAPOR MONITORINGE] 4 AUTOMATIC TANK GAUGING E:l 5 GROUND WATER MONITORING <br /> ANK TESTING O 7 INTERSTITIALMONITORING 0 91 NONE E-1 95 UNKNOWN E:] 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO❑ <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 <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 /> (PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I.D.# <br /> COUNTY# JURISDICTION# FACILITY# TANK 111, 3Iwo zz- <br /> � <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE( !<--Z( �yZ <br /> FORM 8 (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED../IIII� <br /> OOk3B1 <br /> �i <br />