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.n. �., <br /> un <br /> * STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM BIt <br /> � og <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �,k" <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLYC TE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �`B TANK REMOVE <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: <br /> C. DATE INSTALLED(MO/DAYNEAR) pwyby D. TANK CAPACITY IN GALLONS: <br /> II.TANKC NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. L-YJ 1 MOTOR VEHICLE FUEL 4 OIL B. C a REGULAR 3 DIESEL 6 AVIATION GAS <br /> UNLEADED a 2 PETROLEUM 80 EMPTY lz1 PRODUCT 1b PREMIUM 0 4 FUEL L <br /> JET <br /> 7 METHANOL <br /> UNLEADED 5 ET 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 DOUBLE WALL F--] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) F-] 99 OTHER 1 <br /> B. TANK 1 BARE STEEL F-] 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F--] 5 CONCRETE F-� 6 POLYVINYL CHLORIDE a 7 ALUMINUM D 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE E:l 10 GALVANIZED STEEL 0 95 UNKNOWN O 99 OTHER <br /> 1 RUBBER LINED E::] 2 ALKYD LINING 3 OXY LINING 4 PHENOLIC LINING `. <br /> C INTERIORLIN NO0 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION F-] 1 POLYETHYLENE WRAP F-] 2 COATING 3^ VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION [�:] 91 NONE FL�/95 UNKNOWN E::] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 i <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WFRP j <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION cul 95 UNKNOWN A U 99 OTHER 9 <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 0 3 INTERSTI IALg OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> a 1 VISUAL CHECK a 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE EJ,65 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1. TIMA D TE LAST UDMO/D YNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> 4f ' SUBSTANCE REMAINING ll <br /> fJ. GALLONS INERT MATERIAL? YES' NO <br /> THS FORM HAS BEEN COMPLETED UND N F P U TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRI T I N UR - DAT , <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER I"i)c MPOSED OFTHE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD.# �� w � ` `; ' <br /> c>> <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> I, <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. t <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTINGT+IE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (12-91) <br />