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STATE OFCAUFOFHA <br /> `r ti <br /> r <br /> STATE WATER RESOURCES CONTROL BOARD <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 1?r6 CHANGE OF INFORMATION 07 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM _� 2 INTERIM PERMIT F-1 4 AMENDED PERMIT [::] 8 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: q—7 /-rIM;;�[{ , <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.Ill �- S. MANUFACTURED BY: /s <br /> C. DATE INSTALLED(MOIDAYNEAR) f{>. 0. TANK CAPACITY IN GALLONS: ly 54) <br /> II.TANK C TENETS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A I 1 MOTOR VEHICLE FUEL 0 4 OIL B. C. REGULAR <br /> LE H 3 DIESEL � 8 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY PRODUCT 16 PREMIUM 4 GASAHOL 0 7 METHANOL <br /> UNLEADED ❑ 5 JET FUEL <br /> I_ 3 CHEMICAL PRODUCT Lj 95 UNKNOWN Q 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D� IF(A 1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.v: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 0 95 UNKNOWN <br /> SYSTEM IL J 2 LE WALL Fj 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK i BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WlFIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIRLE W/FRP <br /> (PrlmaryTank) El 9 BRONZE O 10 GALVANIZED STEEL Ej 95 UNKNOWN 0 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING Ej 3 OXY LINING I] 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES. NO— <br /> D.CORROSION CI 1 POLYETHYLENE WRAP 0 2 COATING © 3 INYL WRAP Ej 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION 0 91 NONE 2T 95 UNKNOWN O 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION l-w2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A1)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 I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A fj FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL WICOATING A U 8 iD0% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 8 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTIN4 5 MONITOTRING ITIAL ❑99 <br /> OTHER <br /> V.TANK LEAK DETECTION <br /> [--I I VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING 4 AUTOMATIC TANK QAuamG Ej 5 GROUND WATER MONITORING <br /> TANK TESTING 7 INTERSTITIAL MONITORING E:j a1 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO[DAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS 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 9 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY if JURISDICTION# FACILITY A TANK <br /> STATE I.D.# c o `7 /�lr Cl�F3 <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE eT y'e't -1r <br /> FOrtM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOROM48-R4 <br />