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STATE OF CALIFORNIA 1 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> 0 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. I/ <br /> MARK ONLY Q 1 NEW PERMIT F-1 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Ory PERMANENTLY CLOSED ONSITE <br /> (12 T <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 9 TEMPORARY TANK CLOSURE 8 TANK REMOVED ILII ` <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �l <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 1 <br /> A. OWNER'S TANK I.D.A C) B. MANUFACTURED BY: K, <br /> C. DATE INSTALLED(MO(DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> lcop <br /> ILTAN�KCONTENTS IF A.I IS MARKE D.COMPLETE ITEM C. <br /> A L� MOTOR VEHICLE FUEL O 4 OIL B. C. AUNLEADED AR 3 DIESEL O 8 AVIATION GAS <br /> �, /, 4 6ASAHOL <br /> 2 PETROLEUM a BO EMPTY LJ ' PRODUCT O ibUNLEADED Q 5 JETFUEL 7 METHANOL <br /> O 3 CHEMICAL PRODUCT 0 95 UNKNOWN a 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.9: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C,AND ALL THAT APPLES IN BOX D AND <br /> A. TYPE OF [:j I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEMS SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) O W OTHER <br /> BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL F-� 5 CONCRETE E:] 6 POLYVINYL CHLORIDE 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTAnk) 09 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING E] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOP O 5 GLASS LINING F9 UNLINED ❑ 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100 METHANOL? YES_ NO— <br /> D.CORROSION O I POLYETHYLENE WRAP O�2 COATING 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION Da-'S' NONE 95 UNKNOWN 0 99 OTHER .�,,��[[�� <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) a OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)� <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A® 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A V 95 UNKNOWN A U 90 OTHER <br /> C. MATERIAL AND AI BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION E:] I AUTOMATIC LINE LEAK DETECTOR GZ2 LINE TIGHTNESS TESTING Q MONROBING Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> E] 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION O IC 3 VADOZE MONITORING O 4 AUTOMATTANK GAUGING O 5 GROUND WATER MONITORING <br /> TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN 00 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATJL T i$E0(MO/DAY/VR) 2.ESTIMATED QUANTITY OF n3.WAS TANK FILLED WITH YES ��NO <br /> U J SUB STA NCE REMAINING ter GALLONS INERT MATERIAL? <br /> THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICDANTS NAME ^ DATE <br /> (PRINTEA 9iGxATUREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER 5 COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY a JURISDICTION N FACILITY 9 I TANK <br /> STATE I.D.# m c� I I I I I y g D 3 L <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EP(PIRATION DATE 1� <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH TF" OCAL AGENCY IMPLEMENTING THE UNDERGROUND STOP';E TANK REGULATIONS <br /> FORM 6 (1291) _ *Alo y `� <br />