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w<` " e <br /> STATE OF CAUPORNIA +, <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� e <br /> � . 1 0 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY Q 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED Fc <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# -P^ //- B. MANUFACTURED BY: <br /> Q' <br /> C. DATE INSTALLED(MDAY/YEAR) /" K ^ D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFAA IS MARKED,COMPLETE ITEM C. <br /> A, 1 MOTOR VEHICLE FUEL O 4 OIL B. C. Q 1 U REGULAR <br /> 3 DIESEL 6 AVIATION GAS <br /> 4 GASAHOL <br /> O 2 PETROLEUM O 80 EMPTY �RODUCT Ib NLNUM O 5 JETFUEL D ] METHANOL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE 2 LEADED O g9 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.a.AND C.AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 UBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> B. TANK D 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM O 8 100. METHANOL COMPATIBLE WIFRP <br /> (PrimaryTank) O 9 BRONZE O 10 GALVANIZED STEEL UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING O 3 EPO LINING E:] 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING 0 5 GLASS LINING 8 UNLINED 5 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION F7 1 POLYETHYLENE WRAP 0 2 COATING VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 0 91 NONE 95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE 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 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 STIES /COATING A U 9 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 2 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U W OTHER <br /> O. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 0 MONRORING EJ 99OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 0 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN 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 /> SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES O NO 0 <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 SIGNATURE) <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.# m = I I I z 7 �Irn <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A/HAS BEEN FILED. /4/JJ <br />