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77 <br /> A 77- <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED ' / <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY 10 UNKNOWN <br /> A. OWNER'S TANK I.D.# -7 1 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) r� D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C.� <br /> A ,� 1 MOTOR VEHICLE FUEL 4 OIL B. C• 1aREGULAR <br /> UNLEADED 3 DIESEL 6 AVIATION GAS <br /> 2 PETROLEUM BO EMPTY �PROOUCT 1b PREMIUM O 4 JET FUEL 7 METHANOL <br /> UNLEADED 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 F—] 1 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN , <br /> v SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) El <br /> 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> w MATERIAL F--� 5 CONCRETE F-] 6 POLYVINYL CHLORIDE 7 ALUMINUM a 8 100°/ METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE E:l 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O <br /> LINING 5 GLASS LINING F--] 6 UNLINED 99''UNKNOWN Ej 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP F <br /> PROTECTION [�:] 5 CATHODIC PROTECTION 0 91 NONE ['•3UNKNOWN 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 V SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A Vl SINGLE WALLA 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 COMPATIBLEW/FRP <br /> PROTECTIONA U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TES ING 3 IN ERSTI IAL <br /> MONITORING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING F--] 5 GROUND WATER MONITORING s <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING 91 NONE: 95 UNKNOWN a 99 OTHER 41 <br /> VI.TANK CLOSURE INFORMATION e Y'e ka ic:Q ,� 4 A <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> I SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <br /> ti <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 a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THEFOURNUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE 04 �, I �� : , y / t < Ti <br /> PERMITNUMBER 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 TAN REGULA ION <br /> FORM 8,(12-91) �r» �' t �..1 �' ! t I IJ r C e FOR00346 R6 <br />