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`. .IIIIIII, <br /> STATE OF CALIFORNIA _ c�i^ <br /> ' STATE WATER RESOURCES CONTROL BOARD w�� 'P <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >n �> a <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED D / I- <br /> DSA OR FACILITY NAME WHERE TANK IS INSTALLED: 9 ` 1Y/ <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(DAYIYEAR) D. TANK CAPACITY IN GALLONS: of WO <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. }}��� <br /> A 1 MOTOR VEHICLE FUEL � 4 OIL B.�/ C. l taUNLEADED REGULAR 3 DIESEL 6 AVIATION GAS <br /> 2 PETROLEUM O 80 EMPTY 1TC1 1 PRODUCT O 1b PREMIUM 4 JETFUEGASAHOL O 7 METHANOL <br /> !---1 UNLEADED O 5 JET FUEL <br /> O 3 CHEMICALPRODUCT [:_] 95 UNKNOWN a 2 WASTE O 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.III: <br /> III. TANK CONSTRUC N MARK ONE ITEM ONLY IN BOXES A.3,AND C,AND ALLTHAT APPLIES IN BOXO AND <br /> A. TYPE OF O 1 DOUhF WALL O 3 SINGLE WALL WITH EXTERIOR LINERO 95 UNKNOWN <br /> SYSTEM E-12 GLEOuL ED 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL E] 5 CONCRETE O 8 POLYVINYL CHLORIDE O 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) O g BRONZE 10 GALVANIZED STEEL O 95 UNKNOWN O 9 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LNING O 3 EPDXY LINING O 4ENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 6 UNLINED O 95 UNKNOWN 99 O ER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WIT 100% METHANOL7 YES_ NO <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 C TING O 3 VINYL WRAP O 4 FIBERGL REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 0 91 NON O95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALL (YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF U RGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A 7 STEEL W/COATING A U 8 100% METHANOL COMPA LE WIFRP <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 [7 2 LINE TIGHTNESS T ING 3 MONRORING 99 OTHER <br /> MIA <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 A OMATIC TANK GAUGING O 5 GROUND WATERMONITORING <br /> e TANK TESTING �7 INTERSTITIAL MONITORING O 81 NONE O 95 UN WN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED D TE L T USED(MOIDAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO O <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 a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Aon 1IM00,APP Ira <br /> COUNTY# JURISDICTION# FACILITY# TANK III, <br /> STATE I.D.# m <br /> PERMIT NUMBER PERMITAP ROV D YIDA � PERM( E IRAT�N/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. <br /> `/ Nwofle/—/AFOgOal/BR5 <br />