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�ssw• e <br /> STATE OF CALIFORNIA °. <br /> STATE WATER RESOURCES CONTROL BOARD iy <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B m� a_ <br /> COMPLETE A SEPARATE FORM FOR EA NK SYSTEM <br /> MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED nSllE <br /> ONE REM O 2 INTERIM PERMIT d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (D o <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A OWNERS TANK I.D.8 D B. MANUFACTURED BY: u/�4 <br /> C. DATE INSTALLED(MO/DAVHEAR) /L� D. TANK CAPACITY IN GALLONS: <br /> 11.TANK C ENTS IFA-11SMARKED.COMPLETEITEM C. <br /> I MOTOR VEHICLE FUEL d OIL B. / C. 18�N�C'U Ep 8 3 DIESEL O 6 AVIATIONGAS <br /> A LTJ/ <br /> 0 GASAHOL <br /> 0 2 PETROLEUM � BO EMPTY 1 PRODUCT Q 1G NLEADED 5 JET FUEL O 7 METHANOL <br /> 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE 2 LEADED g 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 MARKONE ITEM ONLY IN BOXES A B.AND C.ANDALLTHATAPPLIES IN BOX D <br /> A. TYPE OF BLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 -LE WALL O d SECONDARY CONTAINMENT (VAULTED TANK) Q 90 OTHER <br /> B. TANK 19�1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS Q 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM O 8 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTmk) 0 BRONZE a 10 GALVANIZED STEEL to UNKNOWN Q 09 OTHER <br /> O 1 RUBBER LINED O 2 D LINING 3 EPDXY LINING a 4 PHENOLIC LINING <br /> C.INTN NOR 5 GLASS LINING - ! UNLINED E:] 05 UNKNOWN O 09 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ <br /> D.CORROSION 0 I POLYETHYLENE WRAP a COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 91 NONE O 05 UNKNOWN a W OTHER <br /> IV.PIPING INFORMATIO LE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A AC1 SINGLIWAI A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d 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 E:J I AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING Q 3 INTERSTITIAL <br /> MONITORING <br /> 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING❑ 4,AbOMATIC TANK OAUG#q 6 GROUND WATER MONITORwG <br /> 8 TANK TESTING ] INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN O M OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERTMATERNL? VES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLIAPPLICANTS NAME DATE <br /> C A.r.SN NEI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE MBERS B <br /> STATE I.D.# <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> PERMITNUMBER PERMIT APPROVED BYIDATE PER XPIRATION DATE <br /> FORM B (99q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A CURRENT FORMA HAS BEEN FILED. <br /> FORMS-IM <br />