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STATE OF CALIFORNIA ooi* <br /> STATE WATER RESOURCES CONTROL BOARD ty <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> \ <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY 'K 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED O <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: S u-e, AD <br /> �\ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.03 / B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) /.7;k —9J D. TANK CAPACITY IN GALLONS: a Q DOO <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 0 4 OIL B. C. � la <br /> GA ED EGULAR 3 DIESEL 6 AVIATIONGAS <br /> O 2 PETROLEUM O W EMPTY 1 PRODUCT O 16 PREMIUM 4 GASAHOL 7 METHANOL <br /> O 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE UNLEADED O 99 JOTHER ET L(DESCRIBE IN ITEM D. BELOW) <br /> 2 LEADED O <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF O 1 DOUBLE WALL O 3 SINGLE WALL WITH XTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 GLE WALL 4 SECONDARY CONTAIN NT (VAULTED TANK) O 99 OTHER <br /> B. TANK 1 BAR STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONIC TE O e POLYVINYL CHLORIDE ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE O 10 GALVANIZED STEEL 95 KNOWN 99 OTHER <br /> 0 1 RUBBER LIVINSLLED <br /> ALKYD LINING 0 3 EPO LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINe UNLINED 0 95 UNKNO 99 OTHER <br /> LINING <br /> IS LINING MATERIA100% METHANOL? YES_ NO_ <br /> D.CORROSION O 1 POLYETHY2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC 9/ NONE O95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL COD(YEAR) OVERFILL PREVENTION EOMENT INSTALLED(NEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEG UNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OT R <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 XUBLE WALL A U 3 LINED TRENCH A U 95 UNKN N <br /> A u 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAIN,SS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIB GLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCR A U 7 STEELW/COATING <br /> A U B 1METHANOL COMPATIBLE W/FRP <br /> OTHER PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODI ROTECTION p U 95 UNKNOWN p U 99 OTHER � <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR O 2 LI TIGHTNESS TESTING 0 3 MONITORING 0 99 OTHER <br /> V.TANK LEAK DETECTION <br /> F7 1 VISUAL CHECK 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DAT L T USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO O <br /> SUBSTANCE REMAINING GALLONS 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 <br /> (PRINTED B SIGNATURE) ?� DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW RGaI a yo -w3 <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# m I I 1 1 IQ O <br /> PERMIT NUMBER PERMIT APPROVED BY/DAT 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. <br /> /--/ /- �� FOB003tbR5 <br /> X-4w '� <br />