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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK�SYSTEM.` <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORM''ATK3N ❑ 7 PERMANENTLY:_:SEO ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT4 AMENDED PERMIT ❑ 6 T'EMPORAf1Y TANK CLOSURE <br /> 6 TANK REuO►'c_ <br /> ( DBA OR FACILITY NAME WHERE TANK IS INSTALLED: u— <br /> . I, TANK DESCRIPTION COMPLETE ALL r---VS— SPECIFY IF UNKNOWN <br /> f A. OWNER'S TANK I.D. 8. MANUFACTURED GAvLDNS: 00 <br /> BY: <br /> Al <br /> . I V <br /> C. DATE INSTALLED(MOMAYMEAR) D. TANK CAPACITY IN <br /> I <br /> ILTANKCONTENTS IFA-iISMAFC-'.O„ Z.E,e17EMC. �# <br /> A. S MOTOR VEHICLE FUEL 4 OIL B, C is REGULAR 3 DIESEL r"' E ati'alpn'GAS <br /> Ii LUNLEADED 4 GASOHOL I-- <br /> ❑ 2 PETROLEUM � iL EMP �7 PRODUCT ❑ lb PREM <br /> f ❑ 3 CHEMICAL PRODUCT FS UNKNOWN 2 WASTE I�UNLEADED 5 JET FUEL <br /> ❑ ❑ 2 LEADED 9g OTHER (DESCRI;E -u D.BELOW) <br /> D. IF(A.1)IS NOT VARIED. ENTER NAME o-&:35-A\CE STORED '! <br /> I C.A.S.9: <br /> 4. f <br /> Ill. TANK CONSTRUCTION MARK Oti'E;!v C1LY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN IDX D AND E <br /> A. TYPE OF ❑ t DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER it ❑ 93 UNKNOWN <br /> SYSTEM 2 SINGLE WALL A SECONDARY CONTAINMENT (VAULTED TANK} ❑,6 99 OTHER <br /> I` F7, t BARE STEEL 2 STAINLESS STEEL I3 FIBSRGLACS.3` ❑.I l STEEL Clap w/FIBERGLASS;E'ti-- <br /> = E'PLASTC8. TANK z <br /> - MATERIAL I 1. 5 CONCRETE 6 POLYVINYL CHLORIDE ED7 ALUMINUM 1 ❑�8 IDD% METHANOL COMPATIBLE WcZ <br /> l� (PrimalyTanlla ❑ 9 BRONZE 10 GALVANIZED S7EEL ❑ 95 UNKNOWN ° 199 OTHER F <br /> i. 1 RUBBER LINE' ? 2 ALKY0 LINING 3 EPDXY LININ <br /> G �. 4 PHENOLIC LINING <br /> N, C.1N7EAfOR 7-15 GLASS LINING LINING __ 6 UNLINE'O X195 UNKNOWN 1 99 OTHER <br /> IS LINNG MATERIAL GOM=A T 3.E Ww7.4 10METHANOL? YES_ NO I I <br /> D.CORROSION 1 POLYETHYLENE v.;,L2 _ 2 COATING �❑ 3 VINYL w;A?% ❑;I a FIBERGLASS REINFORCEDL P_AS'C <br /> PROTECTION 5 CATHOOIC PRC`-EC-.C% 61 NONE 9S UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CON7AIVE\7 AS-ALLEO(YEAR OVERFILL Ps•,EVENTKFI:IEOUIPuENT INSTALLED(YEA <br /> IV.PIPING INFORMATION CIRC----- A G;OU!:'OR U IF UNDERGROUND.BOTH IFAPPOCABLE_ y <br /> A. SYSTEM TYPE A 1 SUC7ION A U 2 PRESSURE A U 3 GRAVITY j A U 99 OTHER <br /> P <br /> I <br /> B. CON s7RucTION A U t SINGLE WAIL A U 2 poL19LE WALL A U 3 LINED TRENCH AU45 UNKNOWN A U w G SER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> II 11 <br /> CORROSION A U 5 ALUMNUM A U 6 CONCRETE A U 7 SIE L W.COATING A U 8 10M METHANOL CCV--A71nLE WrFIP <br /> PROTECTION A U 9 GALVAti':2<D S-EL A U 10 CATHODICPF07EC710H A 45 UNIKNOWN j A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LNELEAK DETECTOR 2 LINE 71GH7NESS TESTING ��� 1bHrTOIaIwS � 99 OTHER <br /> V.TANK LEAK DETECTION I ;r <br /> I�I 1 VISUAL CI4ECK ❑ 2 INVENTORY ;ECO%CIL!A710.N ❑ 3 VADCZE MONITORINGAUTOMATIC TANK GAUGING ❑ 5 GROUNDWA-;uON17ORING <br /> I 6 TANK TES7N-G 7 INTEnSTIT:A:MDti•-O:;+'.G h 91 N'O%E 95 UINKNOWN�i 99 OTYIER <br /> Vl.TANK CLOSURE INFORMATION I� <br /> 1-ESTIVILTEJD C7E AST!Is D(MO"OAY.Y;) 2 ES"iV A?ED O:,AL�'-Y OF - �; 3.WAS TALK FILLED WITH YES i NO <br /> S'�BS7ANCEREMA-ti':NG _GALLONS i1 INERT MATE RIAL <br /> iF s <br /> 7NlS FORM HAS BEEN COMPLETED CINDER PENAL 7Y OF PEAJlJRY, AND TO THE 8 T OF KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> LOCAL A I <br /> GENCY USE ONLY THE STATE[.D.NUMBER 1S COMPOSED OF FOUR NUMBERS BELOW ;! <br /> COUNTY 0 JURISDICTION n FACtLiTY i TANK 6 <br /> { STATE I.D.# <br /> TEE;MIT NUMBER PERMIT APPROVED BY.,-ATE ] PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS'A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FCnM$ (t79�] i�- <br /> I! I k]I:Y�61IA <br /> 1 <br />