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-GWJ- f <br /> STATE OF CALIFORNIA °. <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR 4CH TANK SYSTEM <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ s AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED roll <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A A 44 `A �S <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A OWNER'S TANK L D.♦ B. MANUFACTURED BY: 0 K- <br /> C. DATE INSTALLED(MO/DAYNEAR) il K 0. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-I ISLIARKEO.COMPLETEITFMC. v <br /> A I MOTOR VEHICLE FUEL ❑ a OIL C• la <br /> GULAR LEADED 3 DIESEL ❑ 8 AVIATIONGAS <br /> ❑ 2 PETROLEUM ❑ 80 EMPTYPROOUCT Ib PREMIUM a GASAHOL ❑ 7 METHANOL <br /> UNLEADED 5 JETFUEL <br /> ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D. IF(Ai)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.•: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tmk) ❑ 9 BRONZE ❑ 10 GALVANRED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING a PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL) YES_ NO— <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP a FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHOOK: PROTECTION 91 NONE ❑ 95 UNKNOWN 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND.BOTH IFAPPLICABLE <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 A FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 8 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 U 93 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRCRNQ ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 8 TANK TESTING ❑ 7 NTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED(MO/OAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO❑ <br /> SUBSTANCE REMAINING GALLONS NERTMATERIAL7 <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 /> IPRIHTa9 a SIGKAnnF) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY 9 JURISDICTION 9 FACILITY R TANK# <br /> STATE I.D.# 2,6 ® F3 z7 D I 1 101011091 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORMS (990 THIS FC HM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> ._ WRamt6IM <br />