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STATE OF CALIFORNIA '�.• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> a.° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ��' <br /> o Y/ � o <br /> J, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.or <br /> MARK ONLY a 1 NEW PERMIT F7 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION0- 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM a 2 INTERIM PERMIT = 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE �4f 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Og 1 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.X B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA•1ISMARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B. C- taUNLEADED H REGULAR 3 DIESEL 6 AVIATION GAS <br /> 4 GASAHOL <br /> 2 PETROLEUM a 80 EMPTY 1 PRODUCT 1bPREMIUMUNLEADED 0 5 JET FUEL 7 METHANOL <br /> 3 CHEMICAL PRODUCT a 95 UNKNOWN 2 WASTE 2 LEADED 0 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: <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 D 1 DO LE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 0 2 SINGL WALL a 4 SECONDARY CONTAINMENT (VAULTED TANK) a 99 OTHER <br /> 1 BARE STE C <br /> NLESS STEEL 0 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK YVINYL CHLORIDE a 7 ALUMINUM a 8 100% METHANOL COMPATIBLEW/FRP <br /> MATERIAL s CONCRETE(PrimaryTank) 9 BRONZE LVANIZED STEEL a 95 UNKNOWN a 99 OTHER <br /> fRUBBER LINED D LINING a 3 EPDXY LINING a 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LININGINED � 95 UNKNOWN a 99 OTHER <br /> LININGtS LINING MATERIAL COMPATIMETHANOL? YES_ NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAPTING 0 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTIONE a 95 UNKNOWN a 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(Y R) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRE URE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBL 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 STAINLES 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 B 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PR TECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [:1 1 AUTOMATIC LINE LEAK DETECTOR [�] 2 LINE TIGHTNESS TESTING 031 NITORING Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK F7 2 INVENTORY RECONCILIATION 71 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING D 7 INTERSTITIAL MONITORING Q 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES = N0� <br /> 1.ESTI TED DA LAS USED( DAY R) SUBSTANCE REMAINING _GALLONS INERT MATERIAL? LJ <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> DATE <br /> APPLICANTS NAME <br /> (PRINTED a 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,# 13 <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) FOR00348-R6 <br />