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• 'oua es <br /> f,R � � C <br /> STATE OF CALIFORNIA hP i <br /> STATE WATER RESOURCES CONTROL BOARD w o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> t 0 <br /> COMPLETE A SEPARATE FORM FOR EACH ANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT F-� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL5p5Q.QN SITE <br /> ONE ITEM 2 INTERIM PERMIT F--] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E:] 8 TANK REMOVED /��, <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �/ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.#©Z, B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) 2 b 1 <br /> D. TANK CAPACITY IN GALLONS:W u <br /> II.TANK CO TENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL E::] 4 OIL B. C E 1a RE EADED ULAR 3 DIESEL a 6 AVIATION GAS <br /> 2 PETROLEUM a 80 EMPTY PRODUCT ib PREMIUM D 4 GASAHOL 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN O 2 WASTE 2 LEADED O 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,8,AND C.AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER E:] 95 UNKNOWN <br /> SYSTEM a 2 SINGLE WALL E:] 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> B. TANK 1 BARE STEEL F-] 2 STAINLESS STEEL 3 FIBERGLASS � 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F-� 6 POLYVINYL CHLORIDE 7 ALUMINUM 0 8 100°/< METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) E] 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN E] 99 OTHER <br /> 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING E�j 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING ©UNLINED E:l 95 UNKNOWN a 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 0 1 POLYETHYLENE WRAP F-] 2 COATING a 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [::] 5 CATHODIC PROTECTION F-1 91 NONE 0 95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)X94 s 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 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A� 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 �1 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 A U 99 OTHER <br /> D. LEAK DETECTION [�:] 1 AUTOMATIC LINE LEAK DETECTOR D 2 LINE TIGHTNESS TESTING MOl LH51 I]IAL <br /> NITORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE a 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <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 ak _ <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <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 /> FORM 8 (12-91) � <br /> FILE THIS FORM WfrH*LOCAL AGENCY IMPLEMENTING THE UNDERGROUND S AGE TANK REGULATIONS <br /> FOR00546-R6 <br />