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VA F <br /> Fee c <br /> < den <br /> STATE OF CAUSORNIA ' <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B , a <br /> / vCLOSED <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY ON SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 8 TANK REMOVED <br /> MARK ONLY � ❑ q AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE <br /> ONE ITEM 2 INTERIM PERMIT / I n <br /> DBAOR FACILITY NAME WHERETANK IS INSTALLED: <br /> GIAGD n <br /> FANK DESCRIPTION COMPLETE ALL SPECIFY IF UNKNOWN B MANUFACTURED BY: <br /> OWNERS TANK I.D.# vDATE INSTALLED(MOIDAY/YEAR) <br /> e D. TANK CAPACITY IN GALLONS: (/ <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. ❑ 1a REGULAR 3 DIESEL ❑ 6 AVIATIONGAS <br /> FUEL❑ i <br /> ❑ 4 OIL B. C• UNLEADED 4 GASAHOL <br /> A MOTOR VEHICLE ❑ T METHANOL <br /> 1 PRODUCT ❑ 1bEEAI ❑5 JET FUEL <br /> OTROLEUM ❑ 80 EMPTY ❑ 2 WASTE E] UN DED <br /> 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> S CHEMICAL PRODUCT ❑ 95 UNKNOWN OAS#: <br /> Qi(/(1 <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B,AND C,AND ALLTHAT APPLIES IN BOXD 95 UNKNOWN <br /> ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> A. TYPE OF ❑ 99 OTHER <br /> SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIB RGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B, TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ALUMINUM <br /> ❑ g 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL ❑ ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> (Primary Tank) ❑ 9 BRONZE <br /> ❑ 2 ALKYD LINING EPDXY LINING ❑ 4 PHENOLIC LINING <br /> ❑ 1 RUBBER LINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR ❑ 5 GLASS LINING E] 8 UNLINED <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES 9 ISL WRQ ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING <br /> D.CORROSION 5 UNKNOWN ❑ 99 OTHER <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, <br /> BO GRF VPTM)CABLE A U O <br /> 1 SUCTION A U 2 PRESSURE A U <br /> A. SYSTEM TYPE A U A U 2 DOUBLE WALL A U 3 LINED TRENCH A U UNKNOW A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL <br /> A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 ""INVL CHLORIDE(PVC) 4 FIBERGLASS PIPE <br /> C. MATERIAL AND A U S ALUMINUM A U 6 CONCRETE A U T STEEL W/ A U 6 100% METHANOL COMPATIBLE W/FRP <br /> CORROSION 10 CATHODIC PROTECTION p U 9 UN OWN p U 99 OTHER <br /> PROTECTION A U 9 GALVANIZED STEEL A U 3 INTERS)TIAL ❑gg OTHER <br /> 7 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONRORING <br /> D. LEAK DETECTION ❑ <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 UTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> ❑ 6 TANK TESTING ❑ T INTERSTITIAL MONITORING ❑ <br /> 91 NONE BS UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION 3.WASTANKFILLEDWITH YES NO <br /> 2.ESTIMATED OUAill 1111: GALLONS INERT MATERIAL? ❑ <br /> 1.ESTIMATED DATE TUE O AV/YR) SUBSTANCE REMAINING <br /> D <br /> THIS ORM HAS BEEN COMPLETED UNDER PENALTY <br /> FOF PERJURY,A TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# <br /> COUNTY# JURISDICTION# CILITY# <br /> STATE I.D.# [�] -)-5 N 1 <br /> /70 z <br /> MIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE <br /> FORM B (890) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Fo9om4gRa <br /> • � V <br />