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E5° " P9 <br /> _ - STATE OFCALIFORMA J Pot^ <br /> STATE WATER RESOURCES CONTROL BOARD 3,;,�, `y'm <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ;" ,, <br /> �. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �.°""�" <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O ] PERMANENTLY CLOSED ON <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O B TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CY6 S <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.• / B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: Soo <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. 1bR LEADED O 4 DIESEL L 6 AVIATIONGAS <br /> O 2 PETROLEUM O 80 EMPTY 1 PRODUCT O 1bUN PREMIUM <br /> 7 METHANOL <br /> O 5 JET FUEL <br /> 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAhk <br /> OF SUBSTANCE STORED C.A.S.R: <br /> III. TANK CONSTRUCTION MAR NE 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 2 SINGLE WALL Ej 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> O <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE 8 POLYVINYL CHLORIDE O ] ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) O 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN O 98 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING O UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> 18 LINING MATERIAL COMPATIBLE WITH 1 METHANOL? YES_ NO_ <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 TING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 0 91 N E 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 IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESS E A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE ALL 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 STAINLESSTEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A 11 5 ALUMINUM A U B 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 P OTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION E-] 1 AUTOMATIC LINE LEAK DETECTOR � 2 LI TIGHTNESS TESTING MONRORNG � OTHER <br /> V.TANK LEAK DETECTION <br /> 0 i VISUAL CHECK 0 2 INVENTORY RECONCILIATION O 3 VADOZE NITORING 0 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING 0 7 INTERSTITIAL MONITORING O 91 NONE 0 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LA TUBED O/DAY/YR) 2-E <br /> ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O <br /> SUBSTANCEREMAINING 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 SIGNATURE( <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY x JURISDICTION FACILITY# TANKR <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 W G7.QJ d lo" ! 79 Ste ffi W S 7 F <br /> p ► Y' o se �lw. -f-eaa-.*lae-�'?dAeit <br />