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• • <br />STATE OFCAUFORNIA Sc'; <br />STATE WATER RESOURCES CONTROL BOARD ���tiFe --. m o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >r - , <br />I <br />rnMPLFTE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK <br />ONE <br />ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL <br />ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED <br />PERMIT ❑ 5 CHANGE OF INFORMATION <br />PERMIT ❑ 6 TEMPORARY TANK CLOSURE <br />❑ <br />ED <br />7 PERMANENTLY CLOSED <br />TANK REMOVED <br />ON S1TI <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />Z 5ekv <br />Ap" - /4aor Ak4- MGN <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />In'IN lCVICI lq!1mnWN <br />IN <br />I. IAK ulmovnw <br />lrI ON mrLuc ALL <br />.--..... - <br />A OWNER'S TANK 1. D # B. MANUFACTURED BY: L. . <br />C DATE INSTALLED(MO/DAV/YEAR) 9 'J/ D. TANK CAPACITY IN GALLONS. /2, !ice <br />II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. <br />751 to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />A OTOR VEHICLE FUEL ❑ 4 OIL B. C' b PflEMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL <br />❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ le MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 <br />❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REMO. BELOM <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A S. #: <br />CTION 0 E ITEM ONLY IN BOXES A B AND C AND ALL THAT APPLIES IN BUX u ANU e <br />III. TANK CONSTRU MARK N <br />11� DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR UNER <br />❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br />A. TYPE OF <br />SYSTEM <br />I❑n <br />Kj <br />L�2 SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />❑ 99 OTHER <br />A <br />1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM <br />❑ B 100% METHANOL COMPATIBLE W/FRP <br />(PLIm9tyTWW <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />10 CATHODIC PROTECTION <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />LINING OR <br />❑ 5 GLASS LINING <br />'T!� 6 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES _ NO— <br />D. EXTERIOR <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION <br />❑ 5 CATHODIC PROTECTION ❑ 91 NONE <br />95 UNKNOWN <br />❑ 99 OTHER <br />PROTECTION <br />SPILL CONTAINMENTINSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT -1 ALLIED <br />NO DISPENSER CONTAINMENT YES_ NO <br />E. SPILL AND OVERFILL, eIC. OROPTUBE YES_ <br />NO_ STRIKER PLATE YES_ <br />IV. YIF INU IINrUNIVIA IIVIl GIMGLt ---- - _ ---- ------- --.-.-- <br />JURISDICTION # <br />FACILITY # TANK # <br />E� <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A <br />2 PRESSURE A U <br />3 GRAVITY A U <br />4 FLEXIBLE PIPING A U 99 OTHER <br />B. CONSTRUCTION <br />A V I SINGLE WALL <br />A U <br />2DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />CORROSION <br />PROTECTION <br />A U <br />A U <br />A U <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZED STEEL <br />A U <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE <br />7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br />A095 UNKNOWN A U 99 OTHER— <br />D. LEAK DETECTION <br />❑ <br />1 MECN ICAL UNE LM ❑ <br />DETECTOR <br />2 E TMWNESS ❑ 3 CCMINUCIIS INTEASTDML ❑ 4 EIECIZC UNE ❑ <br />IN <br />TESTING MOMTwmG 1PAX DE1EcroR <br />5 AUf01MBL PUMP E:]99 OTHER <br />SHUTDOWN <br />r,nu <br />I. IAINK LEAN VCIIZ.IIVI� <br />ANNUAL <br />❑ 1 VISUAL CHECK � 2 MANUALILATIONORY ❑ 3 MONOITORING ❑ 4 GAUGING IC TANK ❑ 5 GROUND MONITORING �R TANK <br />RECONC❑ 6 TESTING <br />❑ 7 MONTINUOUG INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANKLY MANUAL ❑ 10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER <br />ITORIN <br />VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) <br />1. ESTIMATED DATE LAST USED (MO/DAV/YR) 2. ESTIMATED QUANTITY OF 9. WAS TANK FILLED WITH YES [:]NO❑ <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br />__...._.__.._.. ., ,..,, .—I 1.ecT nc AAV WAInW Fnr'F IR TRNF AND CORRECT <br />THI, <br />rUKM MAO ocall-- <br />DATE <br />TANK OWNER'S NAME <br />(PRINTED E SIGNANRE) <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # <br />JURISDICTION # <br />FACILITY # TANK # <br />E� <br />c.r <br />S�i�9G <br />STATE I.D.# ® <br />= <br />% <br />LJI <br />PERMIT NUMBER <br />PERMIT APPROVED BY/OATE <br />PERMIT EXPIRATION DATE <br />TUIC POR <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- FORM A, UNLESS A GUHHtN I rUKMA MROPPPNr,��. <br />FORM B (6-95) SHOULD BEACCOMPANIED BYAPLOT PLjfLETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ,•.,•••-•••--•----••••--•---------- - - <br />GROUND STORAGE TANK REGULATIONS <br />FOP003/6R7 <br />