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• STATE OF CALIFORNIA • °°"es�, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ; <br /> 0 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, <br /> O M� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ ED PERMIT 4 AMEND ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 6 TEMPORARY TANK CLOSURE E] 6 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> -Do > G,0 L� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.♦ <br /> S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TAANE&ONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A.7((A1) <br /> MOTOR VEHICLE FUEL ❑ 4 OIL B. 1a REGULAR ❑ 3 DIESEL <br /> PETROLEUM ❑ C ❑ UNLEADED 6 AVIATION GAS <br /> 60 EMPTY 1 PRODUCT 1b PREMIUM ❑ 4 GASAHOL <br /> CHEMICAL PRODUCT ❑ 95 UNKNOWN K2 WASE UNLEADED ❑ 5 JET FUEL 7METHANOL <br /> OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A,B,ANDC,AND ALLTHATAPPLIES INBOX D ND <br /> A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> SYSTEM ❑ 95 UNKNOWN <br /> 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANKJ ❑ 99 OTHER <br /> B. TANK ❑ 7 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS <br /> I�}' ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 4' 7 ALUMINUM <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 0 1W. METHANOL COMPATIBLE W/FRP <br /> ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING <br /> C.INTERIOR ❑ 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN <br /> ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? _ <br /> ES_ NO <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP --- <br /> PROTECTION ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Lt:r95 UNKNOWN <br /> ❑ 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) _ <br /> OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION IRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE CTION A U 2 PRESSURE <br /> A U 3 GRAVITY A U 98 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL <br /> A U 3 LINED TRENCH NKNOWN p U 99OTHER <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 <br /> PROTECTION U 7 STEEL W/COATING A U 9 1009: METHANOL COMPATIBLE W/FRP <br /> A U 9 GALVANIZED STEEL p U 10 CATHODIC PROTECTION Adog>NKNOWN <br /> D. LEAK DETECTION [1] 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING A U 99 OTHER <br /> V.TANK LEAK DETECTION MONRORING ❑ 99 OTHER <br /> FE 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE <br /> ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MD/DAY/VR) 2.ESTIMATED OUANTITYOF <br /> SUBSTANCE REMAINING 3.WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? YES ❑ 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 /> (PRINTED a SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# <br /> STATE I.D.# ^^ TANK# <br /> EPERMITNUM-8ER P RMIT APPROVED BY/DATE j <br /> PERMIT EXPIRATION GATE G` � � � 9 <br /> .L b <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> • • fOR0�p5 <br /> L <br />