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.�I 'F l0 9 t. <br /> STATE OFCALIFORMA �t is <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �: <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CL SED ONSITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE B TANK REMOVED O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: i-� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.A B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) 3 D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A. O 1 MOTOR VEHICLE FUEL O 4 OIL B. C. O 1aREGULAR UN EADED 3 DIESEL 0 6 AVIATKINGAS <br /> O 2 PETROLEUM 0 SD EMPTY 1 PRODUCTO .-PREMIUM 4 GASAHOL O 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE 0 2 LEADED a 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A 1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED CAS#: <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 O 11 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM [�J 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM F-1 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) E:j 9 BRONZE 10 GALVANIZED STEEL ED 95 UNKNOWN ED N OTHER <br /> F7 1 RUBBER LINED O 2�ALKYD LINING F-1 3 EPDXY LINING E:] 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING fie UNLINED O 95 UNKNOWN O B9 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING F7 3 VINYL WRAP a 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION EL;, f NONE O 95 UNKNOWN O 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 Ql SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 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 B 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 0 2 LINE TIGHTNESS TESTING 5 WERSTITIA <br /> MONrrORING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> F7 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DAT LASTUSED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLEDWITH <br /> SUBSTANCE REMANING GALLONS INERT MATERIAL? YES E 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 DATE <br /> (PRINTED 8 SIGNANREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBERS COMPOSED OF THE FOUR NUMBERS BELOW It, <br /> COUNTY# JURISDICTION# FACILITY# TANK#p0 TATUK <br /> STATE LDA COUNTY <br /> —Is D Ko: I 3 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> 7 <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM 6 (12-91) oo'8 <br /> PoP06148-R6 <br />