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ua < <br /> STATE OF CALIFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD i 'es ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B w�� "° <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY O i NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT [-] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.x d B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MODAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> A MOTOR VEHICLE FUEL O 4 OIL B. C. Q tAUNLEAD REGULAR 3 DIESEL a 6 AVIATION GAS <br /> O 2 PETROLEUM O 80 EMPTY 1 PRODUCT O 1D PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED Q 5 JET FUEL <br /> 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME bf SUBSTANCE STORED C.A.3.S: <br /> III. TANK CONSTRUCTION MARK ONE EM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF O 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM F-12 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> I BARE STEEL OSTEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL Q 5 CONCRETE O CHLORIDE O 7 ALUMINUM O 8 1009: METHANOL COMPATIBLE W/FRP <br /> (PimaryTank) O 9 BRONZE OD STEEL O 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED LINING 3 EPDXY LINING Q 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE�WF\A10D% MEOL? VES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP 0 2 COATING 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION O 91 NONE 95 UNKNOWN O 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDER ROUND.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 U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U i 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 U STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESSTE ING 3 MONRTITIAL Q 99 OTHER <br /> ORING <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING 0AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 9/ NONE O 95 UNKNOWN 099 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1 ESTIM TED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WASTANK FILLED WITH <br /> AYXSUBSTANCE REMAINING GALLONS INERT MATERIAL? YES O NO <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 /> IiRINTED 6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW lam- Q <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# E= b1-01 / 1x9rJj, 160101061f] <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMM1 A,UNNLE,S/S�A CURRENT FORM A HAS/1BEEN FILED. <br /> EENFILED. <br /> 1� FORO¢N6R1 <br />