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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> C_-� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EAC K SYSTEM <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ? p 5- <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S—TANK D.i B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: 3 <br /> II.TANK CONTENTS IFA-1 IS MARKED.COMPL EMC. <br /> FEGULAR <br /> A O 1 MOTOR VEHICLE FUEL 4 OIL B. C O 1eUN EADED 3 DIESEL O 6 AVIATION GAS <br /> lb PREMIUM 4 GASAHOL 0 7 METHANOL <br /> O 2 PETROLEUM O 00 EMPTY Q 1 PR UNLEADED 5 JETFUEL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN WASTE O 2 LEADED 0 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: <br /> III. TANK CONSTRUCTIO MARKONEITEMONLYINBOXESA.B.ANDC,ANDALLTHATAPPLIESINBOXDANDE <br /> A. TYPE OF UBLE L = 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 S E WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> 1BARE STEEL 2 STAINLESS STEEL D 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL s CONCRETE <br /> 6 POLYVINYL CHLORIDE a 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> D <br /> (Primary Tank) 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED O ALKYD LINING O3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LININGNLINED 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% THANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP = ATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE O0 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR UIF UNDERGROUND.B ABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE _A ITV A U 99 OTHER <br /> B. CONSTRUCTION A U 1 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 U 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 E:] 1 AUTOMATIC LINE LEAK DETECTOR O2 LINE TIGHTNESS TESTING MONITORING O 99 OTHER <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN O 99 OTHER <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 INERT MATERIAL? YES O NO <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 /> IYRINTE9 a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# -)1FACILITY# � TANK# IFF/�jLp <br /> STATE I.D.# � L <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE L <br /> :A'l <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS <br /> �/ / <br /> BEEN <br /> /FILED. <br /> / J <br /> / *—BERS <br />