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i f I �6JugftP <br /> STATE OF CALIFOANA <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 /> i <br /> MARK ONLY L I NEW PERMIT ❑ 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION u 7 PERMANENTLY ri�-Z—V <br /> ITE <br /> ONE ITEM C 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1,54 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OwNER'S TANK I.D.x B. MANUFACTURED BY: dell, <br /> C. OA-E INSTALLED( MOIOAYYEAR) D. TANK CAPACITY IN GALLONS: v L r� <br /> II.TANK CO S IF A•11SMAPIKE D.COMPLETE ITEM C. Y <br /> A. 1 MOTOR VEHICLE FUEL a OIL B, /- C 1a qE LEADED o 3 DIESEL 6 AVIATION GAS <br /> j ry <br /> i� 2 PETROLEUM � 80 EMPTY I vI 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED Cj 5 JETFUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN I 2 WASTE 2 LEADED El 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.F <br /> Ili. TANK CONST RU O N MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF I DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL A SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B, TANK <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLOR;OE 7 ALUMINUM S 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 FOXY LINING a PHENOLIC LINING <br /> C.INTERIOR — 5 GLASS LINING 8 UNLINED 95 UNKNOWN 9g OTHER <br /> LINING LJ <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 INFORMATI CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY 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) U FIBERGLASSPIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION CI 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING ❑ 3 INT RSTIIAL OTHER <br /> M(]NrrORMG 3�is)V.TANK LEAK DETECTION <br /> 1 VISUAL CHECKj;7 <br /> NTORY RECONCILIATION 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING INTERSTITIALMONITORING 91 NONE a 95 UNKNOWN 0 99 OTHER <br /> VI,TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIOAYlYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANCE REMAINING GALLONS 1. INERT MATERIAL? <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED A%GNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY 4 JURISDICTION x FACILITY x TANK x r ' <br /> STATE i.D. Zz (.� <br /> PERMIT NUMBER PERMIT APPROVED 8Y/DATE PERMIT EXPIRATION DATE <br /> FORM B (9.901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORO"I4 -RA <br /> 0 <br />