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tyOJa t <br /> C ^ <br /> ^t ,u.u• J <br /> \.r STATE OF CAUFORMA <br /> STATE WATEa RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE ASEPARATE FORM FOR EACH TANK SYSTEM. O T PERMANENTLY CLOSED ON SITE <br /> O 3 RENEWAL PERMIT 5 CHANGEINFORMATIONO B TANK REMOVED <br /> MARK ONLY Q 1 NEW PERMIT PERMIT O 4 AMENDED PERMIT S TEMPORARY <br /> Y TANK CLOSURE <br /> ONE ITEM 2 INTERIM (a <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 2Z 2Z s• <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS PECIFY IF UNKNOWN B MANUFACTURED BY: <br /> A. OWNERS TANK I.D.N D. TANK CAPACITY IN GALLONS: <br /> C. [)ATE INSTALLED(MO/DAYIYEAM ✓ M1�/' <br /> II.TANKCONTENTS IFAAISMARKED,COMPLETE ITEM C. O 1a REGULAR � 3 DIESEL O e AVIATION GAS <br /> 4 OIL B. O. UNLEADED 4 GASAHOL 7 METHANOL <br /> A i MOTOR VEHICLE FUEL O 1 PRODUCT O ,bUN«'DED O 5 JETFUEL <br /> SO EMPTY UNKNOWN <br /> O 2 PETROLEUM �ASTE 2 LEADED a 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> 0 3 CHSMICALPRODUCT O 96 UNKNOWN O C.A.S.#: <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STOPED <br /> p Oil <br /> III. TANK CONSTRUCTION MARK ONE ITEM OY3 SONG EAWALL WITH E%TERIORTLINERIESIN BOXD❑ 85 UNKNOWN <br /> O t DOUBLE WALL 99 OTNER <br /> A. TYPE OF 4 SECONDARY CONTAINMENT (VAULTED TANK) Q <br /> SYSTEM SINGLE WALL <br /> �eARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B TANK 0 B 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL 5 CONCRETE s POLYVINYL CHLORIDE 7 ALUMINUM <br /> (Primary Tank) 0 B BRONZE Q 10 GALVANIZED STEEL O 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING � 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING � 6 UNLINED UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ — <br /> O 1 POLYETHYLENE WRAP � 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION Lj UNKNOWN O 99 OTHER <br /> PROTECTION 5 CATHODIC PROTECTION O 91 NONE LJ�" ", <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 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 WI COATING A U B 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [] 1 AUTOMATIC LINE LEAK DETECTOR ] 2 LINE TIGHTNESS TESTING ] 3 MONROPoNGL Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> F7 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 0 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBGA <br /> STANCE REMAINING LLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# I IL1C0 2Z <br /> STATE I.D.# = O �/ O D <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> -29- L 5 <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br />