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ey,uA.e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �, ;>� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY [��l <br /> NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO ONOSI <br /> ONE ITEM INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> Ll i�71 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED:, ) ;�clo (�� 1 ! f <br /> I. TANK DESCRIPTION COMPLETE A L ITEOS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ri <br /> ILTANKC NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B, C 1a REGULAR 3 DIESEL <br /> A. UNLEADED 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY PRODUCT O lbPREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED E] 5 JET FUEL <br /> 3 CHEMICAL PRODUCT a 95 UNKNOWN O 2 WASTE E:] 2 LEADED E:] 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 CONSTR TION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF 1 DOUBLE WALL F-� 3 SINGLE WALL WITH EXTERIOR LINER 1:1 95 UNKNOWN <br /> SYSTEM F-� 2 SINGLE WALL a 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL EV3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING ''----WW 5 GLASS LINING 0 6 UNLINED 0 95 UNKNOWN E] 99 OTHER <br /> _ <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE D 95 UNKNOWN F-] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 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 U ' 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A 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)jo <br /> 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 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL <br /> MONITORING gg OTHER <br /> O <br /> V.TANK LEAK DETECTION <br /> FE] <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION a 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING � 5 GROUNDWATER MONITORING6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DAT L T USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETE , N R P F U THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AP ICANTS NAME ol DATE <br /> (P NA <br /> a- <br /> LOCAL AGENCY USE ONLY THEATE I.D.NUMBER OMPOSED OFTHE FOUR NUMBERS BELOW <br /> STATE I.D.# <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> � <br /> - 3-z7 <br /> PERMIT NUMBER PERMIT A OVED 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 /> 3-- <br /> I <br />