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STATE OF CALIFORNIA ••••, `i <br /> STATE WATER RESOURCES CONTROL BOARD fu 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT ❑ 0 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERM <br /> ONE ITEM j 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORMY TANK CLOSURE ❑ 8 TANK RE O 1 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D. S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) U D. TANK CAPACITY IN GALLONS: <br /> II.TANKC ENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL ❑ 6 OIL 8. C. ❑ 1iUNL ULAR ED 0 DIESEL ❑ 8 AVIATION GAS <br /> A a GASAHOL <br /> 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 19 NLEADED a S JET FUEL ❑ 7 METHANOL <br /> ❑ 7 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 90 OTHER (DESCRIBE W ITEM 0.BELOW) <br /> D. IF(At)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.x: <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 ❑ 0 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL F-12 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PdmuyTWt) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 2 EPDXY LINING ❑ A PHENOLIC LINING <br /> C.INTERIOR S GLASS LINING ❑ 6 UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 VINYL WRAP ❑ ♦ FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ S CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ g9 OTHER <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 S GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 0 LINED TRENCH A U 9S UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U R STAINLESS STEEL A U 0 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE <br /> CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEELOCOATIND A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTOKO ❑ J IMNOTMTORmG ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ S VAPOR MONITORING❑ a AUTOMATK:TANK GAUGING ❑ S GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 NTERSTITLLLMONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 2.WAS TANK FILLED WITH YES [:] NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT <br /> 1GPoAPPLICANTSI1iE0A NE DATE <br /> 9gNI"AMNRq <br /> LOCAL AGENCY USE ONLY THE.STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW UJ <br /> COUNTY 6 JURISDICTION 6 FACILITY 6 TANK N <br /> STATE I. Rb&3 EEEp <br /> PERMIT NUMBER : / PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (9.901 THIS,FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOW0t6JM <br />