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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W81 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �J <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATIONQ[;a--g <br /> 7 PERMANENTLY CLOSED ONSITE o <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT a TEMPORARY TANK CLOSURE L.IJ 6 TANK REMOVED 1174111 <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: FI-Q'J'/�'—I� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN F1 <br /> A. OWNER'S TANK I.D.4 Ol B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MODAY/YEAR) D. TANK CAPACITY IN GALLONS: OW <br /> II.TANK CONTENTS IFA-IISMARKED.COMPLETEITEM C. <br /> A O 1 MOTOR VEHICLE FUEL [P--4 OIL B. C. 1a REGULAR <br /> 3 DIESEL O 6 AVIATIONGAS <br /> 0 2 PETROLEUM 80 EMPTY � l PRODUCT O 1b PREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADEDJET FUEL <br /> O 3 CHEMICALPRODUCT Q 95 UNKNOWN O 2 WASTE O 2 LEADED �99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED pAO ; 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 = 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 0 95 UNKNOWN <br /> SYSTEM V--Z-SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> B. TANK 5? BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL = 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM Q B 100% METHANOL COMPATIBLE W/FRP <br /> (PrimmyTmk) O 9 BRONZE O 10 GALVANIZED STEEL 0 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING E0`6 UNLINED E::] 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP [O]/2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> 32 <br /> PROTECTION 0 5 CATHODIC PROTECTION 91 NONE O95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) A <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE AM i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U S9 OTHER <br /> B. CONSTRUCTION A l 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 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 U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION D 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING O 9 INTERSTITIAL <br /> MONITORING O 99 OTHER <br /> V.TANK- K DETECTION <br /> 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> lioore TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DAT LAST SED(MO/DAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES dN0 O <br /> 6=4 911 1 SUB STAN �G <br /> CEREMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS hEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> PRINTED A SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / 7J <br /> COUNTY# JURISDICTION# FACILITY# TANK# -2 <br /> STATE I.D.# m Fm I Li L{ g116 10-1 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMS (12-91) <br /> FORS[G1bR6 <br /> �/ \400, <br />