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STATE OF CALIFORNIA �'. a 4 <br /> STATE WATER RESOURCES CONTROL BOARD -q <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> L '4 o. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE REM F--j 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOV <br /> DBA OR FACILITY NAME WHERE TANK ISINSTALLED: �J <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# D B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) yk D. TANK CAPACITY IN GALLONS: <br /> II.TANK CO IFA-1 IS MARKED,OOMPLETE ITEM C. <br /> A. i MOTOR VEHICLE FUEL q OIL B. C. :[::] <br /> la REGULED 3 DIESEL 6 AVIATK)NGAS <br /> 2 PETROLEUM 80 EMPTY 1 PROCUCT 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE2 LEAD D UNLEADEO O S JET FUEL <br /> 9B OTHER (DESCRIBE IN REM D. BELOWI <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.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 F-] 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER <br /> O 95 UNKNOWN <br /> SYSTEM SINGLE O 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PNmaryTmk) O 8 BRONZE O 10 GALVANIZED STEEL F--] 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR <br /> 5 GLASS LININGED 95 UNKNOWN O 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING 3 VINYL WRAP O4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTIONNONE O95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <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 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 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 99 OTHER <br /> D. LEAK DETECTION L__] MONITORING 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING 3 AL 99 OTHER <br /> V.TANK LEAK DETECTION <br /> F1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING O 6 GROUND WATER MONITORING <br /> e TANK TESTING F7 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> /.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDQUANTITY OF 3.WAS TANK FILLED WITH VES <br /> SUBSTANCE REMAINING GALLONS I INERTMATERIAL? <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 /> (PRINTED a SIGNATIIRE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# 5 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 11-12--165 <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEER FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMS (12-91) <br /> i' iJ FONODII&R6 <br />