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.. �../ <br /> STATE OF CALIFORNIA � <br /> STATE WATER RESOURCES CONTROL BOARD �` .,,• <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B <br /> o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY F-1 1 NEW PERMIT [:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT I] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 S TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO'DAYNEAR) D. TANK CAPACITY IN GALLONS: w ✓��� <br /> II.TANK CONTENTS IFA-11SMARKED,COMPLETEITEM C. <br /> A. 'IS T[ 1 MOTOR VEHICLE FUEL O 4 OIL B. C. <br /> la REGULAR <br /> 3 DIESEL O 6 AVIATION GAS <br /> 2 PETROLEUM O SO EMPTY 1 PRODUCTlb PREMIUM 4 GASAHOL 7 METHANOL <br /> 0 UNLEADED 5 JET FUEL O <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN 0 2 WASTE 2 LEADED 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 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 0 3 SINGLE WALL WITH EXTERIOR LINER BS UNKNOWN <br /> SYSTEM 1^2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) a 99 OTHER <br /> B. TANK 1 RARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS 0 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE 0 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PdmwyTmk) O 9 BRONZE 0 10 GALVANIZED STEEL ❑ 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING O 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C.INTERIOR <br /> E] 5 GLASS LINING �6 UNLINED 95 UNKNOWN E_] 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO_ <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION X91 NONE D95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YE <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 AE>5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR L] 2 LINE TIGHTNESS TESTING WNRORING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK a 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING a 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> i.ESTIMATED DAT L TSI�ED O/DAY/YR) 2.ESTIMFILL <br /> ATED QUANTITY OF 3.WAS TANK ED WITH <br /> `y- 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 <br /> 1"RiNreo a sicNATUR6I DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# = <br /> PERMIT NUMBER IFERMITAPPROVED 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. <br /> FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> E x E m p T TANK `fb ..� r e tyvo��eC� rt�T�u�/� ,, a J� 3 C�091/6R6 <br /> 1 <br />