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'•' I rxd' i ,'t �SOVRC[5 h <br /> STATE OF CALIFORNIA r °i <br /> STATE WATER RESOURCES CONTROL BOARD a` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> v� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTL QS SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REM ED f <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> r I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: v <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> $- <br /> A. �1 MOTOR VEHICLE FUEL 4 OIL 8. C• Q 1aUNLEADED 3 DIESEL � 6 AVIATION GAS <br /> 0 2 PETROLEUM F-180 EMPTY 211 PRODUCT E] 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE a 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOXID AND E <br /> �s A. TYPE OF ❑ OUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ffr2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) E:] 99 OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC, < <br /> B. TANK <br /> MATERIAL5 CONCRETE 6 POLYVINYL CHLORIDE a 7 ALUMINUM <br /> E::] 8 100°/ METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) D 9 BRONZE E] 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> I RUBBER LINED 2 ALKYD LINING [?_EUPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINEDLINING F NKNOWN 99 OTHER I <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 0 1 POLYETHYLENE WRAP F-] 2 COATING El3 -VINYL WRAP E�j 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:�] 5 CATHODIC PROTECTION F-] 91 NONE 95 UNKNOWN F-] 99 OTHER a, <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 /> f.' A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 11 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 11.-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 1001% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 m NRrT'TI ORING IAL r�1 99 OTHER <br /> MONILJ x� <br /> s z} V.TANK LEAK DETECTION <br /> } ❑ 1 VISUAL CHECK 2,INVENTORY RECONCILIATION 3 VADOZE MONITORING E] 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORINGAo <br /> } 6 TANK TESTING F-� 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN ? 99 OTHER 6 <br /> VI.TANK CtOSURE INFORMATION <br /> FS <br /> TIMAT777 <br /> Ep PATE LAST USED(MQ/�Ar 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> r � SUBSTANCE Li'MAINING GALLONS INERT MATERIAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF'P.Et??JURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> I (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# ' I_I 0 ' <br /> PERM IT NUMBER ERM IT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> I FORMs:.>7-91) THIS FORM WST BE ACCOMPANIED BYAkRMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> g t. <br /> 0H0o346.I* <br /> s <br />