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' ecoua e c <br /> �ftw� STATE OF CALIFORNIA <br /> ,., STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B , o <br /> COMPLETE A SEPARATE FORM FOR EAC K SYSTEM. <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ON SITE <br /> MARK ONLY 1 NEW PERMIT O <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I 5-33 <br /> Un C{5 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> B. MANUFACTURED BY: <br /> A. OWNER'S TANK I.D.# <br /> C. DATE INSTALLED(MOIDAV/YEAR) �Z 9p D. TANK CAPACITY IN GALLONS: 4, Opo -- <br /> ILTANKCONTENTS IFA-11SMARKED,COMP TEM C. <br /> EIGULARA O 1 MOTOR VEHICLE FUEL 4 OIL B. C. O 1#UNLEADED O 3 DIESEL O 6 AVIATION GAS <br /> 0 4 GASAHOL O 7 METHANOL <br /> 2 PETROLEUM O 80 EMPTYUCT O 1DPREMUN EAIUM <br /> DED O 5 JETFUEL <br /> O 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WAS a 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRU N MARK ONE ITEM ONLY IN BOXES AB.AND C.AND ALL THAT APPLIES IN BOX <br /> 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER E:] 95 UNKNOWN <br /> A, TYPE OF <br /> SYSTEM Q 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAU 99 OTHER TANK) Q <br /> [Ij 1 BARE STEEL 2 STAINLESS STEEL - 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 1009: METHANOL COMPATIBLE W/FRP <br /> MATERIAL O <br /> (Prlm#ry T9nk) O 9 BRONZE O 10 GALVANIZED STEEL I] 96 UNKNOWN 0 99 OTHER <br /> 1 BEER LINED 2 ALKYD LINING O 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLABS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 VES_ NO— <br /> D.CORROSION Ej] 1 POLYETHYLENE WRAP E] 2 COATING F-� 3 VINYL WRAPFIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 91 NONE O 95 UNKNOWN 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A L 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 965W5 PE <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 Q 1 AUTOMATIC LINE LEAK DETEC'OR O 2 LINE TIGHTNESS TESTING 3 MONRTITIAL 099 OTHER <br /> ORING <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK [--] 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORINGEvr4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUB STANCEREMAINING GALLONS INERTMATERIAL7 YES 0 NOE-1 <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 /> IYRINTED 8 SIGNRTURE) <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.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERM IT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> 1 FORN94&RI <br /> v <br />