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',ALO � f <br /> STATE OF CALIFORNIA L <br /> STATE WATER RESOURCES CONTROL BOARD s' ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM B <br /> ao <br /> .e �„ o'L <br /> rys <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �""°""�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r �J <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOODAYNEAR) D. TANK CAPACITY IN GALLONS: D Od <br /> II.TANKCONTPUS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. F-7 1°R Er' p 3 DIESEL ❑ g pyIATKNJ GAS <br /> A. ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT PREMIUM 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE El <br /> O 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S AND C.AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANKI ❑ 99 OTHER <br /> B. TANK BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINEDUNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEUNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 8a OTHER <br /> B. CONSTRUCTION A SINGLE WALL 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 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 CATHOOICP TION UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETE("'1R 2 LINETIGHTNESSTESTING ❑ 3 jpNRORNG ❑09 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VIS ECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED DUANTITYOF 3.WAS TANK FILLED WITH YES [:] NO❑ <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 <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 /> PAINTEDaSIGMN I <br /> LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ,/ <br /> COUNTY# JURISDICTION FACILITY# TANK# I(Z.CLt4 <br /> STATE I.D.# ms Q o 5 3 3 <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORMS (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.. iG <br /> / PoROm1BRl <br /> L <br />