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' r <br /> STATE OF CALIFORMA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B rrn 4 0 <br /> • CSL ICURlJ9' <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEQ�J ITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> � /J7'� {i'��` •fid/� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-. SPECIFY IF UNKNOWN <br /> --�_ B. MANUFACTURED BY: <br /> =OWNER'SD. D. TANK CAPACITY IN GALLONS: <br /> MOIDAYIYLAR) 1 <br /> II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. L IaREGULAR 3 DIESEL 6 AVIATIONGAS <br /> f 1 MOTOR VEHICLE FUEL 4 OIL B. C UNLEADED 4 OASAHOL a <br /> ❑ 2 PETROLEUM 80 EMPTY 1 PRODUCT IbPREMIUM_UNLEI�I 5 JET FUEL 7 METHANOL <br /> 3 CHEMIGALPRODUCT 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE 4N ITEM D. BELOW) <br /> D. IF(A.iy IS NOT MARKED. ENTER NAME 6F SUBSTANCE STORED <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALLTHAT APPLIES INBOXD <br /> 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A. TYPE OF 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> SYSTEM z SINGLE WALL <br /> ❑ 1 BARE STEEL 2 STAINLESS STEEL ERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 10M. METHANOL COMPATIBLEWIFRP <br /> MATERIAL ❑ 5 CONCRETE <br /> (PrimaryTank) 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-3 2 ALKYD LINING L71 3 EPDXY LINING a 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING ❑ 8 UNLINED r UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL YES— NO— <br /> 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION95 UNKNOWN 99 OTHER <br /> PROTECTION CATHODIC PROTECTION F--I 91 NONE <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY 7E7 <br /> OTHER <br /> B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 99 OTHERC. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDERGLASS PIPECORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI COATING % METHANOL COMPATIBLE WIFRPRROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC P OTECTION 5 UNKNOWNHER <br /> 31r•1TERSTITIAL gg OTHER <br /> D. LEAK DETECTION TOMATIC LINE LEAK DETEf--R 2 LINE TIGHTNESS TE lNG Q <br /> MONITORING <br /> ❑ <br /> V.TANK LEAK DETECTION <br /> ❑ 1 AL CHECK Iii 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING� 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> S TANK TESTING 7 INTERSTITIALMONITORING 91 NONE 95 UNKNOWN 99 ETHER <br /> VI.TANK CLOSURE INFORMATION 3.WAS TANKFILLED WITH <br /> Ll <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF INERT MATERIAL 7 YES NO <br /> SUBSTANCE REMAINING GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> IPRINTED& <br /> ANTS NAME <br /> SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUhiTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# L� Q �` � � �" <br /> PERMIT NUM'i3FR - - PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE _ C^2 <br /> FORM B (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR00346-114 <br />