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STATE OF CALIFORNIA r< o`- <br /> STATE WATER RESOURCES CONTROL BOARD s` '• <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 05 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE <br /> '+ O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S/• J e- <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN /�� ' <br /> A. OWNER'S TANK I.D.% 7=1 <br /> B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MWDAYYEAR) �� D. TANK CAPACITY IN GALLONS: O 000 gajp <br /> ILTANKCONTENTS IFA-)IS MARKED,COMPLETE ITEM C. <br /> A <br /> 1 MOTOR VEHICLE FUEL 0 4 OIL B. C. la REGULAR <br /> O DIESEL O 6 AVIATIONGAS <br /> O 2 PETROLEUM O ea EMPTY O 1 PRODUCT 0 1b <br /> PREMIUNLEAUM O 5 JET FUEL 7 METHANOL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN 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. <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 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK i BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS �4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 0 6 POLYVINYL CHLORIDE 7 ALUMINUM O 6 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTank) 9 BRONZE O 10 GALVANIZED STEEL 0 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED �O/2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING �6 UNLINED � 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAP a 2 COATING O 3 VINYL WRAP X4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 0 9/ NONE O95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A 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 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN U 99 OTHER <br /> D. LEAK DETECTION>551 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING99 OTHER <br /> MONITORING O <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION F—] 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE 0 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED E ST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E NO a <br /> SUBSTANCE R EMAINING GALLONS INERT MATE R IAL? <br /> THIS FO M 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 <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMITNUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE Is <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 /> i <br /> 2—,3 — ? FOROW18R5 <br /> al 7 <br />