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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B W .0 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY u 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMgNENTLY CLOS TE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/OAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-1ISMARKED,COMPLETEITEM C. <br /> A. O 1 MOTOR VEHICLE FUEL 4 OIL B. C. D 1.REG LAR 3 DIESEL O 6 AVIATION GAS <br /> O 2 PETROLEUM O 80 EMPTY O 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> O <br /> ED S JET <br /> 3 CHEMICALPRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED Q HER <br /> O 99 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,B,AND C,AND ALL THAT APPLIES IN BOX D ANDE <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM O 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE a 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED El 2 ALKYD LINING F--] 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED <br /> LINING O 95 UNKNOWN O 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND,BOTHIFAPPLICABLE <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 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING Q 3 MONITORINGQ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> Q / VISUAL CHECK 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING a 91 NONE 95 UNKNOWN O S9 OTHER <br /> VI.TANK CLOSURE INFO MATION <br /> 1.ESTIMATEDop 10 <br /> DA A D V R) 2.ESTIMATED QUANTITY OF VIT 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIALt <br /> THIS FORM HAS BEEAICOMPILETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE <br /> �FOUR <br /> JNUMBERS <br /> BBE�LLO-�W�q/ <br /> STATE LD.# <br /> COUNTY It JURISDICTION# FACILITY#L�LL-I-ILL�._L�J TANK � „y <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIOfIS�?l/ �ROONB96 <br /> FORM B 0291) <br /> �/ <br />