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All C. <br /> STATE OF CALIFORNIA �p� col <br /> STATE WATER RESOURCES CONTROL BOARD . <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> ter , o <br /> •C'�t IFOR N' <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> I <br /> MARK ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ONS <br /> ONE ITEM F—] 2 INTERIM PERMIT 0 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED I ��f' !� '1' a 1 ; , �'1, <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: ) �[ <br /> ` �/ I <br /> C. DATE INSTALLED(MO/DAY/YEAR) f. ("p / C D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> taUN <br /> 3 DIESEL <br /> UNLEADED A 1 MOTOR VEHICLE FUEL 4 OIL B. C. REGULAR D 6 AVIATIONGAS <br /> 2 PETROLEUM E:l 80 EMPTY J PRODUCT �'1bPREMIUM D 4 GASAHOL 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> f 7] 3 CHEMICAL PRODUCT Q 95 UNKNOWN L (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 F71 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN <br /> SYSTEM Ve2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) F7 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE F--] 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) [::] 9 BRONZE E::] 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING 3 EPDXY LINING a 4 PHENOLIC LINING <br /> C.IN <br /> LINING 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION F7 1 POLYETHYLENE WRAP O 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION a 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 IFABOVE 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 i 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 ] 2 LINE TIGHTNESS TESTING 3 MONITORING N RSTI AL 99 OTHER <br /> V.TANK LEAK DETECTION <br /> FF <br /> I 1 VISUAL CHECK 02 INVENTORY RECONCILIATION [:] 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING F—] 5 GROUND WATER MONITORING <br /> 6 TANK TESTING F-1 7 INTERSTITIAL MONITORING a 91 NONE 95 UNKNOWN a 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LA y I PSED(MO/DAY R 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> ? ( G ji' SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED ENALL OFP#RJUPY,AyD TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> .(P NTED GN E) DAT <br /> LOCAL AGENCY USE ONLY THE ST E I.D.NUMBE COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# m <br /> PERMIT NUMBER 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 TANK REGULATIONS <br /> FORM B (12-91) FOR00348-R6 <br />