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GSU`R Ps <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �A <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY Q 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE-- <br /> ONE <br /> ITEONE ITEM F-] 2 INTERIM PERMIT 4 AMENDED PERMIT 0 8 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED Ls-7 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 777 <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A- OWNER'S TANK I.D.4 B. MANUFACTURED BY: <br /> J. <br /> C. DATE INSTALLED(MODAYIYEAR) ilk- 0. TANK CAPACITY IN GALLONS: 3,9 c1 <br /> 11.TANKCON7ENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B, C 1a REGULAR -�r DIESEL g AVIATION GAS <br /> UNLEADED <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT 1b PREMIUM III���JJJ 4 GASAHOL r 1 7 METHANOL <br /> UNLEADED 0 5 JET FUEL L J <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.l)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.III: <br /> ICI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF O rL"DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK <br /> Q 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL r7 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLEWIFRP <br /> (PrimaryTank) Q 9 BRONZE E�l t0 GALVANIZED STEEL 95 UNKNOWN Q 99 OTHER <br /> F7 1 RUBBER LINED ❑ 2 ALKYD LINING 0 3 EPDXY LINING L] 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING 0 5 GLASS LINING UNLINED 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO_ <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP [1] 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION a 91 NONE D95 UNKNOWN E] 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 6 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 4ASINGLE_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 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 STEELWICOATING A U a 100% METHANOL COMPATIBLEWrFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U (UNKNOWN> A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR a 2 LINE TIGHTNESS TESTING ❑ MONITORI GERSTITIAL ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK [!�r2 INVENTORY RECONCILIATION 3 VAPCR MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> S TANK TESTING a 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES D NO <br /> r Y t ' 1 _ ,i, , SUBSTANCE REMAINING GALLONS INERT MATERIAL? <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 8 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.# 3 o u > -/ -71 ERE3 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 /> FOR00148-R4 <br />