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STATE OFCALIFORMA err/ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B <br /> lyi .c <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT D 6 TEMPORARY TANK CLOSURE 9 TANK REMOVED ) O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYiYEAR) D. TANK CAPACITY IN GALLONS: DT/1 <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> (i'CC// <br /> A. O 1 MOTOR VEHICLE FUEL O 4 OIL 9, C Ll la REGULAR 3 DIESEL O 6 AVIATION GAS <br /> UNLEADED 4 GASAHOL <br /> Q 2 PETROLEUM O w4 EMPTY 1 PRODUCT O 1bUNLEAlOEO O 5 JET FUEL O 7 METHANOL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN L 2 WASTE O 2 LEADED O W OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(&I)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 O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANKI O 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE F-1 6 POLYVINYL CHLORIDE 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTmk) O 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> 0 1 RUBBER LINED F--12 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LININ <br /> C.INTERIOR D 5 GLASS LINING I�(I 6 UNLINED � 95 UNKNOWN 99 OTHERLIN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES NO <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION 91 NONE O95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) IVA OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <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 U 99 OTHER <br /> B. CONSTRUCTION A V 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 RARE 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 A U 99 OTHER <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING O 3 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> I VISUAL CHECK O 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O4 AUTOMATIC TANK GAUGING 05 GROUND WATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED fA4LASTjE MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO 0 <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <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 /> (PRINTED A SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW T D lf - <br /> COUNTY# JURISDICTION# FACILITY# TANK# OC) <br /> STATE I.D.# ® I Sl D 1 3 <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> aaj <br /> FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORT MBR5 <br />