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• • te�OJ"CPS <br /> STATE OF CALIFORNIA s, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT �K 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT Ep 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 1317 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I ` 'T-- 44.Ul / <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D. d I B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: DtYj <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ?-rlaUNL LAR 3 DIESEL 6 AVIATION GAS <br /> 2 PETROLEUM O 80 EMPTY 1 PRODUCT 0 1b PREMIUM ❑ 4 GASAHOL 7 METHANOL <br /> UNLEADED O 5 JETFUEL <br /> 0 3 CHEMICAL PRODUCT 0 95 UNKNOWN 2 WASTE 2 LEADED 0 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 F7 11. DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM �r2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) El 99 OTHER <br /> B. TANK v BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F--j 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 09 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING /3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 71 5 GLASS LINING F—] 6 UNLINED 'L_J 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING 0 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTNS <br /> PROTECTION D 5 CATHODIC PROTECTION 0 91 NONE ler95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND,BOTH IFAPPLICA13LE <br /> A. SYSTEM TYPE ACU;1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A1 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 /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A CD15 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION D 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTINGA g9 OTHER <br /> MONRORING O <br /> V.TANK LEAK DETECTION <br /> Q 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORNAO <br /> P�1-6 TANK TESTING 7] 7 INTERSTITIAL MONITORING 0 91 NONE Q 95 UNKNOWN 0 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAV/YP4 2.ESTWATED QUANTITY OF O.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING 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 DATE <br /> IGRINTED 8•IGNATDRE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TAW# /- <br /> STATE LD.# 7 o I <br /> PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE <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 /> 0 0 <br />