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1 <br /> • YLSJJRfp <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> CRI,noNY� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> a <br /> ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE aTANK REMOVED yU�9. <br /> ITVNAMEWHERETANKISINSI III Ell �:5I QCl <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> B. MANUFACTURED BY: <br /> A. OWNER'S TANK LD.# - - <br /> /, y_ L D. TANK CAPACITY IN GALLONS: G <br /> C. DATE INSTALLED(MO/DAVA'EAR) (,{/yl <br /> IL TANK CONTENTS FAdISMARKED.COMPLETEITEMQl.REGULAR 3 D SEL ❑ 6 AVIATIONGAS <br /> i MOTOR VEHIC777V[:7 <br /> C. ❑ UNLEADED SAHOL <br /> A ❑ ❑ UNLEADED ❑ JETFUEL7 METHANOL <br /> 2 PETROLEUM CT 1b PREMIUM3 CHEMICALPROE ❑ 2 LEADED g9 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> C.A.3.#: <br /> III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.B.ANDC.AND ALLTHAT APPLIES INBOX D AND <br /> ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A. TYPE OF - a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> SYSTEM ❑ 2 SINGLE WALL ❑ <br /> PINTERIOR [�] <br /> BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP <br /> BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ING MATERIAL COMPATIBLE WITH 100%METHANOL7 VES_ NO_ <br /> ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION ❑95 UNKNOWN ❑ 99 OTHER <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ gt NONE <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 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 /> RETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP <br /> CORROSION A U S ALUMINUM A U B CONC <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 ❑ 9 NIONRORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 81 NONE ❑ 95 UNKNOWN ❑ 89 OTHER <br /> VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH <br /> 1.ESTIMATED DAT D DlYR) 2.ESTIMATED QUANTITY OF VES [--] NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HA9 BEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF My KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME <br /> (PRINTED a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> # I I TA <br /> YFACILITY# <br /> STATE I.D.# o5l 3TI FM LSBl <br /> PERMIT NUMBERPERMIT APPROVED BVIDATE PERMIT E%PIRATION DATE <br /> FORM 0 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE <br /> wags Rs <br />