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wp <br /> STATE OF CALIFORNIA W.+ °O; <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� e <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �°""�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 MANENTLY CLO 0 TE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: dr dw I <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# otpt/ j B. MANUFACTURED BY: Q14/^J <br /> C. DATE INSTALLED(MO/DIV-A AL-? J D. TANK CAPACITY IN GALLONS: 1,000 <br /> II.TANKC TENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A. EPT 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ;?m-REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS <br /> UNLEADED <br /> ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ lb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADED ❑ 5 JETFUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 0 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)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 D AND <br /> A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ��e2_S!NGUE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 FFyyUNN1044OWN F-] 99 OTHER <br /> F71 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 LINING E::] 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED Ew 9955 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10 METHANOL? YES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-15 CATHODIC PROTECTION [--] 91 NONE 5 UNKNOWN ❑ 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAM OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFA13OVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE Ai SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 89 OTHER <br /> B. CONSTRUCTION A 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 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 W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99INTER IAL <br /> OTH <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 5 MONITORING 0SS OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ d TOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE LZ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATEDD TELASTUS D(MO/DAY/YR) 2.ESTIMATED QUANTITY OF ��// 3.WAS TANK FILLED WITH YES NO <br /> 0 SUBSTANCE REMAINING !"'a6ALLONS I INERTMATERIAL7 ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,A D TC),THE VST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME 1A AE,, <br /> IPRINTEGaSIGNATUREI DATY,io <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NU ER IS COMPOSID OF THE FOUR NUMBERS BELOW <br /> CrnOUNTY# JURISDICTION# FACILITY# TANK# PT Of S/7 <br /> STATE I.Dl [KI] I I 1 .;tl5 7 7 <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> F'080fdBA5 <br />