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`e STATEOFCAUFORMA \/ egoU« c <br /> STATE WATER RESOURCES CONTROL BOARD 3„< i g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. "°""�� <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION n *RMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE a TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.S G - B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: '7/'p D p <br /> II.TANKCO S IFA-11SMARKED.COMPLETE ITEM C. <br /> A. Eyll MOTOR VEHICLE FUEL O 4 OIL B. C. O la REGULAR <br /> 3 DIESEL O 6 AVIATKINGAS <br /> UNLEAD0 2 PETROLEUM 0 SO EMPTY 1 PRODUCT O 1E PREMIUM 4 GASAHOL 7 METHANOL <br /> O <br /> UNLEADED 3 CHEMICAL PRODUCT O 95 UNKNOWN 0 2 WASTE O 2 LEADED I� 9JET L <br /> 9 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> O <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF 1 DOUBLE WALL O D 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> O <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL 0 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE O UMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) a 9 BRONZE O 10 GALVANIZED STEEL .995 Uff_ffU�NKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING �XV LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED 95 UNKNOWN 0 W OTHER <br /> LINING <br /> 9i LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION O i POLYETHYLENE WRAP O 2 COATING ❑ VINYL WRAP E::] 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 91 NONE 95 UNKNOWN 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 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&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 COMPATIBLEW/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ALkC�115 UNKNOWN A U 99 OTHER <br /> O. LEAK DETECTION [_] 1 AUTOMATIC LINE LEAK DETECT'1R 0 2 LINE TIGHTNESS TESTING E MONITOR(GL Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING[_] 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING O 91 NONE E 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS I INERTMATERIAL7 YES O NC EA <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 /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# IFACI TY# INK <br /> STATE I.D.# � D/ t` � <br /> PERMITNUMBER ER MIT APPROVED BY/DATE PERMIT EXPIRATION DATE — 2 4 <br /> FORM B (49D) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> C�FOR0014844 <br /> v <br />