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, .iiia r <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD s 1� <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />•° <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY ❑ 1 NEW PERMIT ❑ <br />3 RENEWAL PERMIT <br />5 CHANGE OF INFORMATION <br />❑ <br />7 PERMANENTLY CLO TE <br />ONE ITEM F72 INTERIM PERMIT ❑ <br />4 AMENDED PERMIT <br />❑ 6 TEMPORARY TANK CLOSURE <br />❑ <br />8 TANK REMOVED7 <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />Li 's l S <br />Li to -E) <br />MATERIAL <br />❑ 5 CONCRETE <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF LINKNOWN <br />A. OWNER'S TANK I. D. ri I <br />B. MANUFACTURED BY: <br />h <br />C. DATE INSTALLED (MO/DAYNEAR) L 6 6 <br />D. TANK CAPACITY IN GALLONS: �i <br />ILTANKCONTENTS IFA-11SMARKED. COMPLETE ITEM C - <br />p ❑ 1 TOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />REGULAR <br />C• aUNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />2 PETROLEUM ❑ 80 EMPTY <br />lf5-1 PRODUCT <br />❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL <br />❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN <br />❑ 2 WASTE <br />UNLEADED El 5 JET FUEL <br />❑ 2 LEADED 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 nNF ITEM nNl Y IN RnyFB A R ANn n ANn AI I TWAT APPI IFC IN Pny n AAIn C <br />A. TYPE OF <br />❑ 1 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 95 UNKNOWN <br />SYSTEM <br />��2 SINGLE WALL <br />❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) <br />❑ 99 OTHER <br />B. TANK <br />1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />F–]3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 100°/ METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />3 POLYVINYL CHLORIDE (PVC) A U <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />❑ 5 GLASS LINING <br />❑ 6 UNLINED <br />�J5 UNKNOWN <br />❑ 99 OTHER <br />LINING <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />- <br />10 CATHODIC P <br />IS LINING MATERIAL COMPATIBLE WITH 100/ METHANOL? <br />YES -S, NO <br />A U <br />D. CORROSION <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3/3 VIN RAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />UNKNOWN <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A <br />2 PRESSURE <br />A U <br />3 GRAVITY <br />A U 99 OTHER <br />B. CONSTRUCTION <br />A(n <br />SINGLE WALL <br />A U <br />2 DOUBLE WALL <br />A U <br />3 LINED TRENCH <br />A U 95 UNKNOWN <br />A U 99 OTHER <br />C. MATERIAL AND <br />A <br />1 BARE STEEL <br />A U <br />2 STAINLESS STEEL <br />A U <br />3 POLYVINYL CHLORIDE (PVC) A U <br />4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />6 CONCRETE <br />A U <br />7 STEEL W/ COATING <br />A U <br />8 1009/ METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC P <br />CTION <br />A U 95 UNKNOWN <br />A U <br />99 OTHER <br />D. LEAK DETECTION <br />UTOMATIC LINE LEAK <br />DETECTOR 2 LINE TIGHTNESS <br />TESTING ❑ 3 <br />❑ 99 OTHER <br />MONITORING <br />V TAAIK I ;:AV n)`TFrT(nM <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO <br />SUBSTANCE REMAINING GALLONS I 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 # JURISDICTION # FACILITY # TANK # <br />STATE I.D.# -'sl I I (o I D D l <br />PERMIT NUMBER PERMIT APPROVED BY/DATE 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 />FORM B (12-91) <br />FOR0734B-R6 <br />❑ 1 VISUAL CHECK <br />❑ 2 INVENTORY RECONCILIATION <br />❑ 3 VADOZE MONITORING <br />,? -1 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br />❑ 6 TANK TESTING <br />❑ 7 INTERSTITIAL MONITORING <br />❑ 91 NONE <br />❑ 95 UNKNOWN ❑ 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 ❑ NO <br />SUBSTANCE REMAINING GALLONS I 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 # JURISDICTION # FACILITY # TANK # <br />STATE I.D.# -'sl I I (o I D D l <br />PERMIT NUMBER PERMIT APPROVED BY/DATE 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 />FORM B (12-91) <br />FOR0734B-R6 <br />