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STATEOFCAUFORMA <br /> -\ STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE A SEPARATE FORM FOR EA ANK SYSTEM <br /> MARK ONLY r �❑�,,��33 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM \ ,I� I ERMIT � 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> DBA OR FACILITP AME WHERE TANK IS INSTALLED: <br /> mk <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# .6*-- O B. MANUFACTURED BY: <br /> B <br /> C. DATE INSTALLED(MO/DAYNEAR) _C? / D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A. � MOTOR VEHICLE FUEL ❑ 4 OIL B. 7E: <br /> REGULAR 3 DIESEL <br /> UNLEADED ❑ 8 AVIATION GAS <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY �l PRODUCPREMIUM 4 GASAHOL ❑ 7 METHANOL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JETFUEL <br /> ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THATAPPLIES IN BOX <br /> A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ®STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E::] 4 PHENOLIC LINING <br /> C.INTERIOR ❑ e 5 GLASS LINING Eel <br /> UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO- <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION Affl 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U t SINGLE WALL A(DP DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 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 Eplr AUTOMATIC LINE LEAK DETECTORE TIGHTNESS TESTING ST( l4l <br /> ❑ 2 LININ EAMONBORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑yVISUAL CHECK INVENTORY RECONCILIATION O3 VAPOR MONITORING❑ 95 AUTOMATIC <br /> UNKNOWN TANK GAUGING O 5 GROgg UND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NOE] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE 104COUNTY# JURISDICTION# FACILITY# TANK# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR00343-PA <br /> /n/ <br />