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• 0 �5�uaces <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B s ka <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE Ix 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �+ G --.OY1G -�-�V- J(. oq <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.x B. MANUFACTURED BY: �1 K. <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1aUN UNLEADED 6 AVIATIONGAS <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. C, 3 DIESEL <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED 5 JETFUEL <br /> 0 3 CHEMICAL PRODUCT �5 UNKNOWN E] 2 WASTE 2 LEADED Fj 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 0 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 1:1 95 UNKNOWN <br /> SYSTEM Qf 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER_ <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL F73 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100°/ METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 0 9 BRONZE El 10 GALVANIZED STEEL [:] 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING F-] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING 6 UNLINED <br /> LINING ©'95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.CORROSION F--] 1 POLYETHYLENE WRAP F72 COATING F-] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:] 5 CATHODIC PROTECTION 91 NONE © 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 &It 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 1 AUTOMATIC LINE LEAK DETECTOR D 2 LINE TIGHTNESS TESTING 3 IN TI IAL <br /> MONITORING u 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 1 VISUAL CHECK F-� 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING F-] 5 GROUND WATER MONITORING <br /> 0 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE [;;�-95 UNKNOWN a 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIM T D DATE LAST USED O DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> I �-/Y SUBSTANCEREMAINING GALLONS INERT MATERIAL? <br /> THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED a SIGNATURE Q` y 420-1, <br /> 2� <br /> d�3 '� <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS C6M2QdD OF THE FO ERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD.# m = I-�'41 [/al <br /> III PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> a3 . q6 <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE <br /> FOR0034&RS <br />