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a.r STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD w 7••�'! o 0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B sp o <br /> 77 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 TANK <br /> REMOVED CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE 1p Na REMOVED Q <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D. B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MQOAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. REGULAR <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B. C 1aUN EA ED O 3 DIESEL 6 AVIATION GAS <br /> O SAHOL <br /> 2 PETROLEUM <br /> EMPTY 1 PRODUCT O 1bUN MADE O 5 JET FUEL 7 METHANOL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED 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 AND <br /> A. TYPE OF �D 11 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM I_`�' 2 SINGLE WALL = 4 SECONDARY CONTAINMENT (VAULTED TANIQ O 99 OTHER <br /> jkf-BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM O 6 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL (] <br /> (Primary Tank) O 9 BRONZE 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> 1 RUBBER LINED F-1 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING n�UNLINED 95 UNKNOWN 0 99 OTHER <br /> LINING v <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSK)N O 1 POLYETHYLENE WRAP ,0, 2,CO�ATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION Fl;-O ^ONE O96 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPEU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND AKU 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 S 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 1 AUTOMATIC LINE LEAK DETECTOR = 2 LINE TIGHTNESS TESTING Q 3 INTERSMIAL <br /> MONITORING D 99 OTHER <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK F-1 2 INVENTORY RECONCILIATION a 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING E�] 5 GROUND WATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE Q 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LASTUSED(M /DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> 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 /> IPR WEU b SIGNATUREI n^ <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ( ' <br /> COUNTY# JURISDICTION# F # <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE RMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS <br /> 'BEEN FILED. <br /> I ////� 7�/ / � yC�2�• FOR�Hv <br />