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4 <br /> .,. „a " STATE OF CALIFORNIA p.. <br /> STATE WATER RESOURCES CONTROL BOARD u o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT Ej 5 CHANGE OF INFORMATION PERMANENTLY CL <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURES TANK REMOVED <br /> i <br /> I <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: . <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: !jai f Al <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: [� 90 <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. L/ <br /> a1aUN 3 DIESEL <br /> UNLEADED A. 1 MOTOR VEHICLE FUEL 4 OIL g, C. 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY IJ PRODUCT lbPREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED a 5 JETFUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED gg OTHER (DESCRIBE IN ITEM D: BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C q S#: <br /> i <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX DAND E <br /> A. TYPE OF �� 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER � 95 UNKNOWN <br /> SYSTEM I vl 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> BARE STEEL 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC j <br /> B. TANK <br /> MATERIAL 0 5 CONCRETE 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 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING <br /> 5 GLA I UNLINED SS LINING 6 NLI ED 95 UNKNOWN <br /> 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP F-],2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION a 5 CATHODIC PROTECTION [:] 91 NONE F_lZ UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAROMWyl <br /> 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&2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 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 8 100°/ METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AaU',95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [�] 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL - gg OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING E::] 4 AUTOMATIC TANK GAUGING E::] 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE E y �5 UNKNOWN F-] 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1. STIMATEQ ATE LAS U-ED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YESNO 0 <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PEN TY OF ROVURY,AWT, THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT.; <br /> APPLICANTS NAME i DATE A{ <br /> ( R TE 8 I NAT <br /> t G. <br /> rol- 7f <br /> LOCAL AGENCY;USE ONLY THE STAB L0.NUMBER IS46MPOSED OF THE FOUR NUMBERS BELOW , <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> �t*TE I.D.# <br /> tY" <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> F THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WrrH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM$(12 9t) • • FOR00346 R6 <br /> Si <br /> �? . a N. uA_ <br />