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y s °ae <br /> N%W SfpTE OF CALIFURMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY O i NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE �TANK REMOVED O f <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5 Z9 ry :c /Z <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAV/VEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A MOTOR VEHICLE FUEL 4 OIL B, C aREGULAR O 3 DIESEL 6 AVIATIONGAS <br /> UNLEADED 0 4 GASAHOL <br /> O 2 PETROLEUM O 00 EMPTY 1 PROWCT ibUNLEADED O 5 JETFUEL ❑ 7 METHANOL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE © 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.x: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA.S.AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF 1Q0 11 DOUBLE WALL D 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> I- <br /> SYSTEM 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER <br /> BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE O 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM O B 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL <br /> (PrimaryTank) O 9 BRONZE 10 GALVANIZED STEEL O 95 UNKNOWN E7] 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 6 GLASS LINING O 6 UNLINED E2-96-UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOLS VES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP F-1 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 0 91 NONE Ea�UNKNOWN O 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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. CONSTRUCT K)N p SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p 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 W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p UNKNOWN A lI 99 OTHER <br /> D. LEAK DETECTION 01 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING 31WNNO RING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING= 4 AUTOMATIC TANK GAUGING [--] 5 GROUND WATER MONITORING <br /> O 8 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONEUNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNA) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> c_ — 5 -115SUB STA NCE REMAINING --- GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> 1PRINTED A SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# S{A/JOSZ <br /> STATE I.D.# LKil I I y 0 ¢ o O p I <br /> PERMITNUMBER PER MIT APPROVED BY/DATE PERMIT EXPIRATION DATE /Z_95 <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 /> ,✓ <br /> FOR60N&M <br /> i <br />