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STATEOFCAUPoRNA <br /> `o <br /> J " e <br /> STATE WATER RESOURCES CONTROL BOARD s4 i� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B m� "�: <br /> COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM <br /> MARK ONLY F7 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLQSEQxIN 317E <br /> ONE REM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT [:] 8 TEMPORARY TANK CLOSURE O 8 TANK REMOVED O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: zez / <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN J <br /> A. OWNERS TANK LD.# B. MANUFACTURED BY: f I is <br /> C. DATE INSTALLEO(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS:V 000 <br /> 11.TANK CONTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A. Q�rl MOTOR VEHICLE FUEL Ej 4 OIL 0. AUN'REBEADED 8 3 DIESEL 8 AVIATION GAS <br /> F 2 PETROLEUM BO EMPTY 1 PRODUCT O 1EPREMIUM 4 GASNK)L O 7 METHANOL <br /> UNLEADED 5 JETFUEL <br /> 3 CHEMICALPRODUCT % UNKNOWN O 2 WASTE O 2 LEADED 99 OTHER (DESCRIBE IN ITEM O.BELOW) <br /> D. IF(AI)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 THATAPPLIES IN BOX <br /> A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 7 % UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TAN19 99 OTHER <br /> S. TANK ❑ 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE 8 POLYVINYL CHLORIDE 7 ALUMINUM O 8 100% METHANOL COMPATIBLE WIFRP <br /> (PNmAryTwk) O 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.URNINGR a 5 GLASS LINING � 8 UNLINED a % UNKNOWN W OTHER <br /> 0 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO- <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 91 NONE O% UNKNOWN Q 99 OTHER <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 % UNKNOWN <br /> 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 8 CONCRETE A U 7 STEEL V#COATING <br /> A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL p U 10 CATHODIC PROTECTION p y 96 UNKNOWN p U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING O 31 MO5 a 99 OTHER <br /> NRDRINO <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING Q 5 GROUND WATER MONITORING <br /> 8 TANK TESTING a 7 INTERSTRIALMONRORING O 91 NONE 95 UNKNOWN Q 09 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOATAY/YR) 2.ESTIMATED OUANTITY OF J.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING [iALLON3 INERT MATERIAL7 YES 0 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 <br /> DATE <br /> IPWNTE9•31(WATURE7 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE LDACOUNTY# JURISDICTION# -�FACILITY# TANK# <br /> � ,?yc o <br /> PERMIT NUMBER PERMITAPPROVED BY PERMIT EXPIRATION DATE <br /> FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE <br /> I ` <br />