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CSOUR,P. <br /> STATE OF CALIFORNIA • �'ti, <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B a� <br /> •C�[IfpR R� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION �0 PERMANENTLY CLOSED ON SI <br /> ONE ITEM 2 INTERIM PERMIT F-] 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE ,y 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z �� l WW a <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/DAY/YEAR) _ D. TANK CAPACITY IN GALLONS: G;l <br /> 4 <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL � 4 OIL B. C. to REGULAR 3 DIESEL � 6 AVIATION GAS <br /> UNLEADED <br /> 2 PETROLEUM 80 EMPTY �1 PRODUCT O 1b PREMIUM O 4 GASAHOL ❑ <br /> 7 METHANOL <br /> UNLEADED 5 JETFUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE O 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 F-� 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) F] 99 OTHER <br /> B. TANKEi-eKl BARE STEEL F--] 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-] 5 CONCRETE F-] 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING 3 EPDXY LINING F--] 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING � 5 GLASS LINING [-] 6 UNLINED V5 UNKNOWN 99 OTHER <br /> 1S LINING MATERIAL COMPATIBLE WITH 100°/ METHANOL? YES_ NO <br /> D.CORROSION D 1 POLYETHYLENE WRAP 2 COATING —� 33 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-] 5 CATHODIC PROTECTION 91 NONE I y x}'95 UNKNOWN F-] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) r, www OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)aqKM <br /> ,) <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 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 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 ST L WlCOATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION D 1 AUTOMATIC LINE LEAK DETECTOR � 2 LINE TIGHTNESS TESTING 3 I ER AL gg OTHER <br /> MONffORING <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK F-] 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING 0 5 GROUNDWATER MONITORING <br /> 0 6 TANK TESTING 0 7 INTERSTITIAL MONITORING 91 NONE r/95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.f;STIMATEP DATEA T USED?(MO/ 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> bv 'vi SUBS ANCE REMAINING GALLONS INERT MATERIAL? <br /> TN)S FORM HAS BEEN COMPLETED UND P A RJ Y,AND HE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> [DATE//, <br /> (PRINTED <br /> LOCAL AGENCY USE ONLY THE STATE I. .NUMBER IS CO OSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# 61 <br /> STATE I.D.# FT-1 = � o <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> I 6 <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 6 (12-91) <br /> 0 <br /> 0 FOR0034B-R6 <br />