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STATE OF CALIFORNIA <br /> STATE WATER,RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B <br /> ( <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE REM O 2, INTERIM PERMIT O d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Xnl 4wAlw= �- <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A OWNER'S TANK I.D.a B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> A 'IL��H�,L 1 MOTOR VEHICLE FUEL Ij d OIL B. C, ❑ 1a REGUUR UNLEADED 3 DIESEL Q 6 AVIATION GAS <br /> r:IN2U <br /> PETROLEUM O 80 EMPTY 1 PRODUCT ❑ lb PREMIUM UNLEADED 4 GASAHOL O 7 METHANOL <br /> 3 CHEMICAL PRODUCT 0 95 UNKNOWN 2.WASTE le MIDGRPDE UNLEADED O 5 JETFUEL O 8 M85 <br /> 2 LEADED Q 99 OTHER IOESCRIBE IN ITEM D.BELOW) <br /> D.__IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C A S a: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF O I DOUBLE WALL Q 3 SINGLE WALL WITH EXTERIOR LINER 0 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL Q 4 SINGLE WALL IN A VAULT 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL olc�5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 09 BRONZE [j 10 GALVANIZED STEEL O 95 UNKNOWN E] 99 OTHER <br /> C.INTERIOR O 1 RUBBER LINED YQ�2 ALKYD LINING Ej 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING OR 5 GLASS LINING 'yC1 6 UNLINED O 95 UNKNOWN 0 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIE EW-I'T�H 100% METHANOL? YES— NOX ! <br /> D.EXTERIOR O 1 POLYETHYLENE WRAP O 2 COATING F7 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> PROTECTION 5 CATHODICPROTECTION91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL,atC. SPILL CONTAINMENT 109STACLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> DROP TUBE YES_ NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> B. CONSTRUCTION A LI)i SINGLE WALL A U 2DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND ABARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A 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 1 MECHANICAL LINE LEY( 2 IBIS MWK WNrINUWS IMERSTIA 4 ELECTRONIC UNE 5 AMmNATIL NW <br /> DETECTGR TESTING MONITOPING TEAK DETECTOR O SHUTDOWN 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK x 2 MANUAL ECONCILIATIONORY ❑ 3 VADOZE MONIITOAlNG 4 AUTOMATGAUGING IC TANK S GROUND MONTORINGTER �4r TE�NGTANK <br /> O T MONITORING G INTERSTITIAL 0 8 SIR E] 9 WEEKLY <br /> GAUGING 10 MO THLY TANK O 95 UNKNOWN �ai,99 OTHER <br /> NG <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) <br /> 1.ESTIMATED DATE LAST USED(MO/DAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES NO� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME DATE <br /> (PRINTEDa 516NATURk� -Y,� <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY a JURISDICTION a FACILITY N TANK 8 <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE F� <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT PLr" FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I^VRGROUND STORAGE TANK i _r REGULATIONS I' A <br /> FORM (6-95) 1 ^'/► — 1 t� fo/'TJ/L 9' <br />