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0 <br /> STATE OFCAUFORNIA :P V•'+ Gy <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> •5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT g TANK REMOVED <br /> [D;OAOR <br /> NLY ❑ ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 1./ <br /> M ❑ 2 INTERIM PERMIT <br /> FACILITY NAMEWHERE TANK IS INSTALLED: Q J/ •� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B MANUFACTURED BY: <br /> A. OWNER'S TANK I.D.# fa <br /> D. TANK CAPACITY IN GALLONS: j 000 <br /> C. DATE INSTALLED(MO/DAY/YEAR) <br /> II.TANK QONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. ❑ taREGULAR ❑ 3 DIESEL 6 AVIATION GAS <br /> 7E] <br /> MOTOR VEHICLE FUEL ❑ 4 OIL B. C UNLEADED ❑ 4/GASAHOL ❑ 7 METHANOL <br /> a 80 EMPTY KWA <br /> RODUCT ❑ ibUNLEAIDED ❑/� JET FUEL <br /> PETROLEUM rTr.I(CHEMICAL PRODUCT <br /> ❑ 95 UNKNOWN STE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> C.A.S.X: <br /> D. IF(A.1j IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED k viJ <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX D <br /> ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> 1 DOUBLE WALL gg OTHER <br /> A. TYPE OF 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ <br /> SYSTEM 2 SINGLE WALL ❑ <br /> ❑ 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK ❑ 6 POLYVINYL CHLORIDEV95 <br /> ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRP <br /> MATERIAL ❑ 5 CONCRETE ❑ 99 OTHER <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN <br /> 1 RUBBER LINED <br /> 2 ALKYD LINING EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 6 UNLINED �el5 UNKNOWN ❑ 99 OTHER <br /> 5 GLASS LINING <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES._ NO— <br /> POLYETHYLENE <br /> D.CORROSION ❑ 1 ppLYETHYLENE WRAP <br /> 2 COATING V95 <br /> VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE <br /> UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A t 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(JY <br /> 95 UNKNO7NA99 OTHERA U 1 BARE STEEL A U 2 STAINLESS STEEL A U3 POLYVINYL CHLORIDE(PVC)A U 4 FC. MATERIAL AND p U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1COMPATIBLE W/FRPCORROSION STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 <br /> N A U 9 GALVANIZED 3 INTERSTITIAL 99 OTHER <br /> PROTECTIO T STING <br /> DETECTION ❑ <br /> 1 AUT <br /> OMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS E ❑ MONITORING ❑ <br /> D. LEAK <br /> V.TANK LEAK DETECTION <br /> =6T CHECK ❑ 2 INVENTORY RECONCILIATION � 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> STING ❑ 7 INTERSTITIAL MONITORING <br /> VI.TANK CLOSURE INFORMATION ::: <br /> 3.WAS TANK FILLED WITH YES ❑ NO ❑ <br /> 2.ESTIMATED QUANTITY OF GALLONS INERT MATERIAL? <br /> t.ESTIMATED DATE LAST USED(MO/DAY/YR) SUBSTANCE REMAINING <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,E IS TRUE AND CORRECT <br /> APPLICANTS NAME <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# <br /> �' r'� <br /> 9f <br /> STATE I.D.# <br /> PERMIT <br /> PERMIT APPROVEDBYIDATE �r^T��f -" <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA, NLES)S A CURRENT FORMA HAS BEEN FILED. Foaom46 R4 <br /> oq <br /> L <br />