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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> ACOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT r-1 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT K 4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.4 7� - 1-1 Al I- -A, 7�NUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) 192- D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONITENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A. [��l MOTOR VEHICLE FUEL 4 OIL B. C. [��la REGULAR 3 DIESEL 6 AVLATIONGAS <br /> UNLEADED 4 GASAHOL <br /> F-1 2 PETROLEUM 80 EMPTY En/I.I"PRODUCT lbPREMIUM 7 METHANOL <br /> UNLEADED s jrTFUEL <br /> 3 CHEMICALPRODUCT 96 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a: <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES&B,AND C,AND ALL THAT APPLIES IN 13OX D Xs- sb <br /> A. TYPE OF [_] DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM W2 SINGLE WALL 4 SECONDARY CONTAINMENT �AULTEDTANK) 99 OTHER <br /> 8. TANK r-1 I RARE STEEL E] 2 STAINLESS STEEL EY'3 FIBERGLASS D 4 STEEL CLAD Wi FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 6 CONCRETE F-1 6 POLYVINYL CHLORIDE F--1 7 ALUMINUM E::] 8 1� METHANOL COMPATIBUEWIFRP <br /> (PrimayTank) 09 13RONZE E�] 10 GALVANIZED STEEL 96 UNKNOWN 99 OTHER <br /> F-] I RUBBER LINED [::] ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR F-1 5 GLASS LINING Ye UNLINED F-1 95 UNKNOWN Ej 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.CORROSION F7 1 POLYETHYLENE WRAP F-1 2 COATING F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F--j 5 CATHODIC PROTECTION F--] 91 NONE F-1 95 UNKNOWN 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION Ad..;P PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL Ajp 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(1>4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 COINCRETE A U 7 STEELWICOATING A U 8 100% METHANOL COMPATIBLE W/FFIP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODI�PAOTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [:] I AUTOMATIC LINE LEAK DETECTOR [?r2 LINE TIGHTNESS TESTING 3 fll�51IIIAL [::]99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> Fj'1'4ISUAL CHECK E?�2 INVENTORY RECONCILIATION F-] 3 VAPOR MONITORING E:] 4 AUTOMATIC TANK GAUGiNGE:] 5 GROUND WATER MONITORING <br /> Zf 6 TANK TESTING E 7 INTERSTITIAL MONITORING F--j 91 NONE Lj 06 UNKNOWN L_:] W OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> I SUBSTANCE REMAINING GALLONS I INERTMATERIAL? YES E NO <br /> THIS FORM 14AS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT <br /> CANTS=' DATE <br /> ED. I. I <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.# <br /> PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> 0-i <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 /> FORMB-PA <br />