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• a <br /> STATE OF CALIFORNIA STATE WATE RESOURCES CONTROL BOARDUNDERGROUNDSTORAG ANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONn VS <br /> CLO <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE LLL�111/S TANK REMOVED D <br /> 71 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S(o 6 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.M B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCO ENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C ❑ to REGULAR ❑ 3 DIESEL <br /> A. UNLEADED ❑ 6 AVIATION GAS <br /> ❑ ❑ 4 GASAHOL ❑ 7 METHANOL <br /> ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT lbPREMIUM <br /> -,,,UNLEADED ❑ 5 JETFUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Lb ` LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOWI <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 THATAPPLIES IN BOX <br /> A. TYPE OF ,❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM L 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK 1 BARE STEEL r72 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR <br /> [-] 1 RUBBER LINED Ll2 ALKYD LINING VPDXY LINING F-] 4 PHENOLIC LINING <br /> LINING F-15 GLASS LINING ED UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> IV,PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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 004ATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A095 UNKNOWN A U 99 OTHER <br /> 1 AUTOMATIC LINE LEAK DETEC''R 2 LINE TIGHTNESS TESTING 31MERSTRIAL <br /> D. LEAK DETECTION _ ❑ —=31M <br /> MONITORING OTHER_ <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3J/APOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATERMONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ,�991 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATEgppT-E LAS USFn1f0/[�AV/VR)_ 2.ESTIMATED QUANTITY OFSUBSTANCE REMAINING NG .__GALLONS 3 WASINERTM TERIALTANK FILLE ITH YES ❑ NO <br /> o!C <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE 101 COUNTY* JURISDICTION# FACILITY# TANK# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B B-90) THIS FORM MUST BE ACCOMPANIED BY <br /> A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORDtt 8-114 <br />