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• tu50Jaff9 f <br /> • STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> STORAGE TANK PERM <br /> UNDERGROUNDS IT APPLICATION a FORM B ,�- <br /> C�IIOnYf <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> 5 CHANGE OF INFORMATION ] RMANENTLY CLOSED ONSITE <br /> ❑ <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT❑ q AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O-/� <br /> ONE ITEM 2 INTERIM PERMIT I <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1.;TANK COMPLETEALLITEMS- SPECIFYIFUNKNOWN B. MANUFACTURE0BY: <br /> ER'S TANK I.D.# �� ©�c/ <br /> D. TANK CAPACITY IN GALLONS: <br /> C. DATE INSTALLED(MOIDAYNEAR) <br /> ILTANKCONTENTS IFMARKED,COMPLETE ITEM C. aFPEGU AR 7W 3 DIESEL ❑ 6 AVIATION GAS <br /> 1 MOTOR VEHICLE FUEL ❑ < OIL 0. C. ❑ UNLEADED 4 GASAHOL <br /> A. O W EMPTY 1 PRODUCT ❑ IbUNLEAIDED ❑ ❑ T METHANOL <br /> 5 JET FUEL <br /> : 2 PETROLEUM <br /> O 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 98 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> C.A.S.K: <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S,AND C,AND ALL THAT APPLIES IN BOX D A❑ND 95 UNKNOWN <br /> ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> A. TYPE OF _ 99 OTHER <br /> SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ <br /> 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> B. TANK ❑ 8 t00Y METHANOL COMPATIBLE WIFRP <br /> ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM <br /> MATERIAL 95 UNKNOWN 99 OTHER _ <br /> (PflmeryTa9k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ <br /> ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> ❑ 1 RUBBER LINED ❑ 99 OTHER — — <br /> C.INTERIOR 6 UNLINED 95 UNKNOWN <br /> ❑ 5 GLASS LINING ❑ <br /> LINING _--- <br /> IS LINING MATERIAL COMPATIBLE WITH JW0 METHANOL? YES_ — <br /> ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP 5 UNKNOWN ❑ 99 OTHER <br /> PROTECTION ❑ <br /> 5 CATHODIC PROTECTION ❑ 91 NONE <br /> E.SPILL AND OVERFILL <br /> SPILL CONTAINMENT INSTALLED(NEAR) 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 <br /> rgZE: <br /> N A U 2 PRESSURE p U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION WALL A U 2 DOUBLE WALL A U 3 LINED TRENYLNCH A U 95 UNKNOWN p U 99 OTHERC. MATERIAL AND TEEL A U 2 STAINLESS STEEL A U ? SEE IW/COATING CHLORINYL DE(PVC)A U 8 100% METHANOL PIPECOMPATIBLE WIFRPCORROSION UM A U 6 CONCRETE A UPROTECTION IZED STEEL p U10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHERD. LEAK DETECTIONTIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING <br /> ❑ J MONITORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VIS U CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> E] 95 UNKNOWN 99 OTHER <br /> TANK TESTING ❑ 7 INTERSTITIAL MONITORING <br /> ❑ 91 NONE <br /> ❑ <br /> VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES ❑ NO <br /> 2.ESTIMATED QUANTITY OF GALLONS INERT MATERIAL? <br /> 1.ESTIMATED DATE LAST USED(MOA R)9 Z— SUBSTANCE REMAINING <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 /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# M K TFA e <br /> COUNTY# JURISDICTION# FACILITY# <br /> =PERMITNUMBER <br /> O 6 5 b 5 0 <br /> PERMIT APPROVED BYIDATE <br /> PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Fogamae-Rs <br /> • Y <br />