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STATE OF CALIFORNIA ���.,i, <br />STATE WATER RESOURCES CONTROL BOARD i �'` <br />W Ebyy <br />� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �,� �s1.,A,� <br />�: <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLYI_ JJ 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br />ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �JDO �L �//G/�Zie j�� /�0,� f E (J(•� <br />1.IAINR UCJlrN1YIIUPi COMP TE ALL ITEMS - SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I.D.% O B. MANUFACTURED BY: <br />C. DATE INSTALLED (MO/DAYNEAR) /9 'J D. TANK CAPACITY IN GALLONS: v, <br />ILTANKCONTENTS IFA.I I.CMARKFII COMPI FTFITFMC <br />A 1 MOTOR VEHICLE FUEL <br />�4 OIL <br />B. <br />C. 1 IAUN <br />SYSTEM <br />3 DIESEL <br />D 6 AVIATION GAS <br />0 2 PETROLEUM <br />0 eD EMPTY <br />PRODUCT1b <br />EADED <br />PREMIUM <br />O <br />3 FIBERGLASS <br />4 GASAHOL <br />O 7 METHANOL <br />O 3 CHEMICALPRODUCT <br />O 95 UNKNOWN <br />�1 <br />2 WASTE <br />UNLEADED <br />O 2 LEADED <br />(PrimaryTurk) <br />5 JETFUEL <br />99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME <br />OF SUBSTANCE STORED. <br />/ <br />4 FIBERGLASS PIPE <br />a 100% METHANOL COMPATIBLE W/FRP <br />99 OTHER <br />C. A. S. <br />ALKYD LINING <br />III. TANK CONSTRUCTION MARK nNP ITEM 11,11 V 1610rnF. RAun c eunen TueTAPPI vn—E <br />A. TYPE OF <br />1 DOUBLE WALL <br />0 3 SINGLE WALL WITH EXTERIOR LINER <br />0 95 UNKNOWN <br />SYSTEM <br />2 SINGLE WALL <br />a 4 SECONDARY CONTAINMENT (VAULTED TANK) <br />O 99 OTHER <br />B. TANK <br />1 BARE STEEL <br />2 STAINLESS STEEL <br />3 FIBERGLASS <br />O 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />5 CONCRETE <br />O 6 POLYVINYL CHLORIDE <br />O 7 ALUMINUM <br />O B 100% METHANOL COMPATIBLE W/FRP <br />(PrimaryTurk) <br />0 9 BRONZE <br />a 10 GALVANIZED STEEL <br />O 95 UNKNOWN <br />O 99 OTHER <br />4 FIBERGLASS PIPE <br />a 100% METHANOL COMPATIBLE W/FRP <br />99 OTHER <br />O 1 RUBBER LINED <br />ALKYD LINING <br />3 EPDXY LINING <br />O 4 PHENOLIC LINING <br />C. <br />LINING INTERIOR <br />5 GLASS LINING <br />K2 <br />a UNLINED <br />O 95 UNKNOWN <br />O 99 OTHER <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL] <br />YES_ NO— <br />D. CORROSION <br />1 POLYETHYLENE WRAP <br />O 2 COATING <br />0 3 VINYL WRAP <br />O 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />Q 5 CATHODIC PROTECTION <br />E] 91 NONE <br />95 UNKNOWN <br />O 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br />IV. PIPING INFORMATION CIRCLE A IFABOVE GROUNDOR U IF DNDFRGROIINn RnTH IF APw Icem c <br />A. <br />SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE A& <br />3 GRAVITY <br />A U 99 OTHER <br />B. <br />CONSTRUCTION <br />1 SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH <br />A U 95 UNKNOWN A U 99 OTHER <br />C. <br />MATERIAL AND <br />CORROSION <br />PROTECTION <br />A U <br />A U <br />A U <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZED STEEL <br />A U <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC)A U <br />7 SIPL.,WICOATING A U <br />A6 UNKNOWN A U <br />4 FIBERGLASS PIPE <br />a 100% METHANOL COMPATIBLE W/FRP <br />99 OTHER <br />D. <br />LEAK DETECTION <br />01 <br />AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 9 <br />INTERSTITIAC <br />MONRORING <br />99 OTHER <br />I. IT—AINK LEAK DETECTION <br />1 VISUAL CHECK 2 INVENTORY RECONCILIATION a 3 VADOZE MONITORING E::] 4 AUTOMATIC TANK GAUGING � 5 GROUND WATER MONITORING <br />6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN O 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ONO <br />SUBSTANCE REMAINING GALLONS IN <br />MATERIAL? <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 4 SIGNATURE) <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR.NUMBERS BELOW <br />COUNTY # JURISDICTION # :FACILITY # TANK # <br />STATE I.D.# c <br />PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE F --w 7 <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILE <br />FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS % e <br />FORM B (12-91) <br />V I'/ �l� v �D4n. FOR09MB116 <br />