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`e 1%01 mope <br /> co <br /> STATEOFCAUFORMA ,` '; <br /> STATE WATER RESOURCES CONTROL BOARD w,,,� v <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 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 0 2 INTERIM PERMIT O 4 AMENDED If <br /> E-] 6 TEMPORARY TANK CLOSURE O8 TANK REMOVED <br /> a Q r <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A 6 / S <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# O B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO(DAYMEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANKC NTENTS IFA-11SMARKED,CCMPLETE ITEM C. <br /> REGULAR <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. 18UNLEADED 3 DIESEL O 8 AVIATION GAS <br /> u 4 GASAHOL <br /> O 2 PETROLEUM O 80 EMPTY /1PRODUCT O 10 NLMIL D O 5 JET FUEL ❑ 7 METHANOL <br /> 3 CHEMICAL PRODUCT 0 95 UNKNOWN O 2 WASTE 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 Am 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 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> O 1 BARE STEEL O 2 TAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK O g YVINVL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL E::] 5 CONCRETE <br /> (PrimuyTWc) O 9 BRONZE O 10 GA ANIZED STEEL a 95 UNKNOWN O W OTHER <br /> a 1 RUBBER LINED O 2 ALKYD INING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED Q 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10096 METRA L7 VES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 0 91 NONE F 95 UNKNOWN 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 1 BARE STEEL A U 2 STAINLESS STEEL p 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 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 O 1 AUTOMATIC LINE LEAK DETEC-nR O 2 LINE TIGHTNESS STING 31MpNRORI GL 0 89 OTHER <br /> V.TANK LEAK DETECTION <br /> Q 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING O 7 INTERSTITIAL MONITORING D 91 NONE E UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO� <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <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 /> (PRINTED 8 SIGNeTUREI <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 /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.) <br /> If 3 P Y I F0 06CBR6 <br /> o T�nl <br />