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STATE OFCAUFORMA �^LyJVR�.gcG <br /> >> <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I <br /> EW PERMIT � 3 RENEWAL PERMIT ❑ S CHANGE OF INFORMATION ❑ 7 PERMANENTLY/CLOSED ON SITE <br /> MARK ONLY ❑ V +� <br /> ONE 1 i EM �N T ERIM PERMIT n 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE ❑i 6 TANK REMOVED !r <br /> C6A OR FACILITY NAME WHERE TANK 15 INSTALLED: 3 <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN �� <br /> =INANK I.D.;l I B. MANUFACTURED BY: ©d r <br /> ED D. TANK CAPACITY IN GALLON ' I <br /> IIJANKC TENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> ❑, 4 OIL 8. C 1a GUL1R 3 IESEL ❑ 6 AVIATI.NGAS <br /> A 1 MOTOR VEHICLE FFUEL UNLEADED 4 GASAHOL <br /> PREMIUM <br /> 2 PETROLEUM ❑ 60 EMPTY PRGDUGT ❑ tbUNLEACED ❑ ❑ 7 METHANOL <br /> 5 JET FUEL <br /> 4-� <br /> 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER {DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.11 IS NOT MARKED. EN R NAME OF SUBSTANCE STORED C.A.S.4 <br /> 111. TANK CONSTRU ION MARK ONE ITEM ONLY IN 80XES A.8.AND C,AND ALL THAT APPLIES IN BOX D <br /> i 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A. TYPE OF 99Z'11HER <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEO TANK) ❑ <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC <br /> B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 t00% METHANOL COMPATIBLE WIFRP <br /> MATERIAL ❑j 5 CONCRETE <br /> (Primary T ank) n 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> 1 ,RUBBER LINED ❑ 2 ALKYD LINING EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH t00k METHANOL? YES_ NO— <br /> 1 CORROSION ❑ t POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 F18EAGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHOOIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING iNFORMATIUN CIRCLE A IFABOVEGROUNDOR U is:UNDEAGROUND,BOTH IFAPPL[CABLE <br /> A. SYSTEM TYPE U t SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> LE WALL A U 3 LINED TRENCH A U 95 UN OWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUB <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)k—fU 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING A U 6 t00% METHANOL COMPAT;BLEWfFRP <br /> PRpTECTION A U 9 GALVANIZED STEEL A U t0 CAT14001C PROTECTION A U 95 UNKNOWN A U 99 OTH <br /> FR- <br /> L3 INT S(TIAL OTHF <br /> D, LEAK DETECTION t AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING LJ IICNFORING <br /> V.TANK LEAK DETECTION <br /> I VISUAL CHECK ❑ NVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> ESTIMAT'eD DATE LAST US'cD(M01DAYNR) 2_ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ -40 ❑ <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> TNlS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE:AND CORRECT <br /> DATE <br /> APPLICANT'S NAME <br /> 19RINTED d SiGNATUFEI <br /> LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY;t JURISDICTION 1i FACILITY# TANK a <br /> STATE I.D. J� i ❑❑ F-7 J' S <br /> PERMITNUMSER PERMIT APPROVEDBYIDATE I PERMIT EXPIRATION DATE <br /> I <br /> FORM R {9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> Ft3FiWA4! <br /> 0 0 <br />