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STATE OF CALIFORMA A <br /> STATE WATER RESOURCES CONTROL BOARD p` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B = <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF <br /> ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE O 8 TANKTION 7 REMED CLOSED ONSITE <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Y 3 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.III B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A. O 1 MOTOR VEHICLE FUEL 4 OIL B. C. O 1.REGULAR <br /> EGU R 3 DIESEL 6 AVIATION GAS <br /> O 2 PETROLEUM O 80 EMPTY 7 PRODUCT O 1E PREMIUM 4 GASAHOL <br /> UNLEADED 5 JET FUEL T METHANOL <br /> 0 3 CHEMICAL PRODUCT 95 UNKNOWN �2 WASTE O 2 LEADED 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED t--J' a S-tv O' C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM FA 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK 'xi 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE e POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Prim#ryTAnk) Q B BRONZE 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> C.INTERIOR O 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING Ej 4 PHENOLIC LINING <br /> LINING 5 GLASS LINING 55fY 6 UNLINED El 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? VES NO_ <br /> D.CORROSION O 1 POLYETHYLENE WRAP 0 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION O 91 NONE 5 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <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 U 2 PRESSURE AQ)3 GRAVITY A U N OTHER <br /> B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN <br /> A U 99 OTHER <br /> C. MATERIAL AND AU BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U S 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 <br /> A u w OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING 3 <br /> 98 OTHER <br /> V.rrTANK LEAK DETECTION MONITORING <br /> u i VISUAL CHECK O 2 INVENTORY RECONCILIATION [-] 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUD NOO 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING Q T INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN <br /> O B9 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTI D DAT LAST US (MO/DAY 2.ESTIMATEDc? q QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <br /> THIS FORM HAS BEEN COMP ED UNDER PENALTY OF PERJURY,AND TO THEBEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Rcc- L D S D itk o e <br /> STATE I.D.# # <br /> COUNTY# JURISDICTION# FACILITY 9 TANK <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. /({'I <br /> FORM H (12-91) <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEME TING THE UNDERGROUND STORAgg NK REGULATIONS <br /> / <br /> oL Ta+I R, f hP�t,.l,cs-v o2— — `1` o �� �,L F BB6 <br />