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STATE OF CALIFORNIA ' o <br /> JJ y i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B y° <br /> ty <br /> COM ETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY a 1 NEW PERMIT EV3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F--j 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED D <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# D 3 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) l D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A F71 MOTOR VEHICLE FUEL a 4 OILB. C. 0 la REGUL R a 3 DIESEL Gl 6 AVIATION GAS <br /> 2 PETROLEUM F--] 80 EMPTY F-] 1 PRODUCT 1b PREMIUM D 4 GASAHOL a 7 METHANOL <br /> UNLEADED- 5 JET FUEL <br /> a 3 CHEMICAL PRODUCT a 95 UNKNOWN 2 WASTE 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 ONE ITEM ONLY IN BOXES A.B,AND C.AND ALLTHAT APPLIES IN BOX D AND E <br /> A. TYPE OF 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER = 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL 0 3 F113ERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> a 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING a 4 PHENOLIC LINING <br /> LINING <br /> C.INTERIOR 0 5 GLASS LINING Q 6 UNLINED a 95 UNKNOWN a 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION O 1 POLYETHYLENE WRAP a 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION a 91 NONE a 95 UNKNOWN 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 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 A U 95 UNKNOWN <br /> A U 99 OTHER <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR [::] 2 LINE TIGHTNESS TESTING E::] 3 IMONN ITORIN1 ALG0 gg OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING O 91 NONE E] 95 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 NO a <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 <br /> (PRINTED 3 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 2 -� <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) c <br /> FOR00348-R6 <br />