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STATE OF CALIFORNIA � +`tyoJR F3 C <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> CSI FpP M`� <br /> COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. <br /> ❑1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> MARK ONLY NEW PERMIT <br /> ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> ONE ITEM 2 INTERIM PERMIT <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> B. MANUFACTURED BY: <br /> A. OWNER'S TANK I.D.A <br /> D. TANK CAPACITY IN GALLONS: /Z- <br /> C. DATE INSTALLED(MO/DAY/YEAR) <br /> gll'F <br /> K CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. taREGULAR 3 DIESEL ❑ 6 AVIATIONGAS <br /> MOTOR VEH;ENTER <br /> ❑ 4 OIL B. C UNLEADED 4 DIESELG�ASAHOL 7 METHANOL <br /> PETROLEUM g�l PRODUCT 1bPREMIUM <br /> 80 EMPTY UNLEADED 5 JET FUEL <br /> CHEMICAL P95 UNKNOWN WASTE ❑ 2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOW) <br /> NOT MARKENAME OF SUBSTANCE STORED <br /> C.A.S.*: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALLTHAT APPLIES IN BOX D <br /> 1 DOUBLE WALL ❑ <br /> 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A. TYPE OF 1�1/ <br /> ❑ <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRP <br /> MATERIAL ❑ 95 UNKNOWN 99 OTHER <br /> (Primary Tank) ❑ 9 BRONZE ❑ <br /> 10 GALVANIZED STEEL ❑ <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED Y11/95 UNKNOWN a 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES._ NO_ <br /> ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING F--­I WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION 95 UNKNOWN 99 OTHER <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> =DETECTION <br /> PE A�1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> TION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> N A U 5 ALUMINUM A U 6 CONCRETE A U 7 STE -W/COATING A U 8 100°/ METHANOL COMPATIBLE W/FRP <br /> N A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER <br /> - <br /> OT <br /> 99 OTHER <br /> CTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ MONRORING ❑ <br /> V.TANK LEAK DETECTION <br /> ❑ N ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATIO <br /> / ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE <br /> VI.TANK CLOSURE INFORMATION 3,WAS TANK FILLED WITH YES ❑ No <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF INERT MATERIAL? <br /> SUBSTANCE REMAINING _::GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PgINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW j <br /> COUNTY# JURISDICTION# FACILITY# <br /> �'q6,b TANK# 1 Z•._ti t- <br /> STATE I.D.# a 3 Yy1t <br /> s`�f�? pr ``- <br /> PERMIT NUMBER PERMIT APPROVED BY/DATES�T9j C <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM ,UNLESS A CURRENT FORM A HAS BEEN FILE D.."� ?�oRa�g R4 <br /> p ss ?��3/��- <br /> 13 qq 0 <br />