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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B nr � <br /> C�tlr pn N� <br /> CO PLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT F-] 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -Z2 V4wvvy" 4,o <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# 7/ B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1a REGULAR 3 DIESEL <br /> A 0 1 MOTOR VEHICLE FUEL F--] 4 OIL 8. C• D UNLEADED � 6 AVIATION GAS <br /> 2 PETROLEUM O 80 EMPTY 1 PRODUCT E:] 1b PREMIUM 4 GASAHOL a 7 METHANOL <br /> UNLEA3 CHEMICALPRODUCT 95 UNKNOWN a 2 WASTE a 2 LEADED <br /> DED- a 5 JETFUEL <br /> 0 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 ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER = 95 UNKNOWN <br /> SYSTEM a 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) El 99 OTHER <br /> B. TANK <br /> 1 BARE STEEL 2 STAINLESS STEEL a 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL L-1 5 CONCRETE F--] 6 POLYVINYL CHLORIDE a 7 ALUMINUM F-] 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) E] 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN O 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING a 3 EPDXY LINING a 4 PHENOLIC LINING <br /> C.INTERIOR (� <br /> LINING 5 GLASS LINING E� 6 UNLINED a 99 OTHER 95 UNKNOWN 0 _ <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAP a 2 COATING a 3 VINYL WRAP F-] 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION O 91 NONE F--] 95 UNKNOWN a 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,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 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 STAINLESS STEEL A U 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 <br /> A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION a 1 AUTOMATIC LINE LEAK DETECTOR a 2 LINE TIGHTNESS TESTING � 3 MONRORING 0 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 7E1 VISUAL CHECK F-] 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING <br /> 6 TANK TESTING a 7 INTERSTITIAL MONITORING 91 NONE a 95 UNKNOWN 0 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 <br /> (PRINTED&SIGNATURE) DATE <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.# m F <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE P RMIT 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) t'h;�af'�� R0034B-R6 <br />