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5UU0.ceS <br /> • STATE OF CALIFORNIA PG °1 <br /> STATE WATER RESOURCES CONTROL BOARDAL <br /> a ^ � <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY F-] 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSEj3rQV TE <br /> ONE ITEM F--] 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSUREB TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - Awib -f-zCz� A/ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CATENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B, C to REGULAR 3 DIESEL <br /> A. UNLEADED 6 AVIATION GAS <br /> 0 2 PETROLEUM 80 EMPTY 1 PRODUCT a lb REMIUM 4 GASAHOL 7 METHANOL <br /> —�NLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT 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 ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF F7 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER E�l 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL F-1 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-] 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) [::] 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED F-] 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO <br /> D.CORROSION 1 POLYETHYLENE WRAP 0 2 COATING 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION D 91 NONE 0 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 1001/6 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 DETECTION1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL <br /> 0 MONITORING 0 99 OTHER <br /> V.TANK LEAK DETECTION <br /> F-1 1 VISUAL CHECK F-] 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING [::] 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING a 7 INTERSTITIAL MONITORING E] 91 NONE O 95 UNKNOWN E] 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED TE LAST USED(MO/DAY/YR) F2.'ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES a NO <br /> SUBSTANCE <br /> 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 DATE <br /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# �j 1� <br /> STATE l'� <br /> I.D.# / <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR0034B-R5 <br /> i • /el - <br />