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�-' STATE OF CALIFORNIA <br /> / STATE WATER RESOURCES CONTROL BOARD <br /> /rIY, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B e <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM a 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED 12PCF <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S Z? t./r`c C/ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# 1 B. MANUFACTURED BY: � A <br /> Ic <br /> C. DATE INSTALLED(MOIDAY/YEAR) U D. TANK CAPACITY IN GALLONS: 40 c';' <br /> II.TANKCONTE S IFA-11S MARKED,COMPLETE ITEM C. <br /> a REGULAR 0 3 DIESEL O 6AVIATIONGAS <br /> A MOTOR VEHICLE FUEL O 4 OIL B. C. UNLEADED <br /> O 2 PETROLEUM O BO EMPTY 1 PRODUCT 0 Ib PREMIUM O 4 GASAHOL O 7 METHANOL <br /> UNLEADED Q 5 JETFUEL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED O 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 <br /> A. TYPE OF F-1 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) E] 99 OTHER <br /> BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL 0 5 CONCRETE O B POLYVINYL CHLORIDE O 7 ALUMINUM O B 100% METHANOL COMPATIBLE W/FRP <br /> (PrimmyTonk) O 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN N OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING F73 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR F-1 5 GLASS LINING O 8 UNLINED UNKNOWN O 99 OTHER <br /> UNING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION 0 1 POLYETHYLENE WRAP a 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION O 91 NONE L; 9N UNKNOWN 0 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A Vi 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 B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(t!jIli UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION D 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINETIGHTNESSTESTING O 31IN1TTERSTITIAL N00RING I] 99 OTHER <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK F-1 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 0 4 AUTOMATIC TANK GAUGING [_] 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 0 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> 19',_ f SUBSTANCE REMAINING <'-'::)GALLONS INERTMATERIAL? YES O NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICARINTEDNTS NAME DATE <br /> (P 8 SIGNRNREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# /�ilq o S 2_ <br /> STATE I.D.# F-?Tll FTTI I I lyloly- v p U <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> .... X7 FORMRll <br />