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STATE OF CAUiORMA 1 �� � 4 <br /> STATE WATER RESOURCES CONTROL BOARD p <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "�� =: <br /> COMPLETE A SEPARATE FORM FOR ANAL SYSTEM. <br /> MARK ONLY Q 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED qN SITE <br /> ONE REM 2 INTERIM PERMIT O A AMENDED PERMIT 8 TEMPORARY TANK CLOSURE O 8 TANK REMOVED - Z� <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.4 �J 8. MANUFACNRED BY: n <br /> C. DATE INSTALLED(MO/DAYNEAfl) !/^ D. TANK CAPACITY IN GALLONS: <br /> II.TANK ENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. la REGULAR <br /> e 3 DIESEL 8 AVIATIONGAS <br /> aNLEA <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE 2UNNLL SOD 5 JETFUEL <br /> 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX O AND <br /> A. TYPE OF ❑ 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> B. TANK ❑ I BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 5 POLYVINYL CHLORIDE 7 ALUMINUM B IOD% METHANOL OOMPATIBLE W/FRP <br /> (Pdmwy TADk) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIORLINING O 5 GLASS LINING 8 UNLINED 95 UNKNOWN O 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH IOD%MET14ANOL? YES_ NO- <br /> D.CORROSION I POLYETHYLENE WRAP 2 COATING O 3 VINYL WRAP 4 F18ERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION O 91 NONE O25 UNKNOWN 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 I 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 8 CONCRETE A U 7 STEELWICOATING <br /> A U B 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANRED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q I AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING Q MONRORNG099 THER <br /> V.TANK LEAK DETECTION <br /> Q 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION a 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING a 5 GROUNDWATER MONITORING <br /> E] 8 TANK TESTING F-1 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN Q 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH ^� <br /> YES <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? NO� <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 SKNNAMFM <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 7 <br /> COUNTV 9 JURISDICTION 9 FACILITY 9 TANK R <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B D2-91) FORINXBNf <br /> I .We �� <br />