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1 � �� <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD NO V Q 5 79 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �� ss° <br /> ENVI ° <br /> RONMEMgI HE <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. PERMIT/SERV q <br /> MARK ONLY 1 NEW PERMIT F--j 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.s B. MANUFACTURED BY: u�L <br /> C. DATE INSTALLED(MQ'DAY/YEAR) 7q I D. TANK CAPACITY IN GALLONS: <br /> ILTANK555CONTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> A yyyi MOTOR VEHICLE FUEL O 4 OIL B. C. Q 1aREGULAR <br /> UNLEA ED 3 DIESEL O 6 AVIATION GAS <br /> 2 PETROLEUM O SO EMPTY 1 PRODUCT O 19PREMIUM 4 GASAHOL O 7 METHANOL <br /> O O ❑ O 95 UNKNOWN 2 WASTE 2 LEADED UNLEADED ❑❑ 99 JOTHER ET L(ESCRIBE IN ITEM D. BELOW) <br /> 3 CHEMICAL PRODUCT <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.i <br /> III. TANK CONSTRUC ON MARK ONE ITEM ONLY IN BOXES A B.ANDC.AND ALLTHATAPPLIES INBOXD <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTED TANK) a 99 OTHER <br /> B. TANK Eg 1 BARE STEEL O 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q S CONCRETE O B POLYVINYL CHLORIDE O 7 ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE O 10 GALVANIZED STEEL 0 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING 6 UNLINED F--j 95 UNKNOWN O W OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH METHANOL? YES_ NO— <br /> D.CORROSION O / POLYETHYLENE WRAP 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 91 NONE ❑ 95 UNKNOWN O 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 ESSU A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 E W 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)A U 4 F LASS <br /> CORROSION A U 5 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 = 1 AUTOMI LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING O 3 INTERSTMAL =99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> I� 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 0 3 VAPOR MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING 0 7 INTERSTITIAL MONITORING 0 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAV R+) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES a NO <br /> Y�GGJ SUBSTANCE REMAINING INS INERTMATERIAL? <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 /> (GRINTED 6 SIGNATu. <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# 3 9 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOxaauBna <br />