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S'UR.fig <br /> STATE OF CALIFORNIA t L- <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B l <br /> c <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT F-� 4 AMENDED PERMIT [�] 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'p:b;q L t <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# uifv�CnRow-wL B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) 4 D. TANK CAPACITY IN GALLONS: C 94/4 <br /> v <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> MOTOR VEHICLE FUEL 4 OIL 8. C. 1a REGULAR <br /> 3 DIESEL 6 AVIATION GAS <br /> A 4 GASAHOL <br /> 2 PETRO'-EUM 80 EMPTY X 1 PRODUCT 1b PREMIUM [�] 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHE:'CAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D IF(A.1;IS NOT:'ARKED, 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 OF1 DOUBLE WALL �'I 3 SINGLE WALL WITH EXTERIOR LINER GI 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL El 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> I BARE STEEL F7 2 STAINLESS STEEL �,x 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> TANK <br /> MATERIAL ! 5 CONCRETE n 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE a 10 GALVANIZED STEEL C 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED � 2 ALKYD LININGa 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.Ira ERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHERb//7 <br /> LINING <br /> S LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YE NO— <br /> D.CORROS;CN __� 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PRO"ECTION 5 CATHODIC PROTECTION a 91 NONE F—, 95 UNKNOWN 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. SYSTEIM 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 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 POMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p©r999 B�OTHER Olftl F&)C <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ps 9 MONfiORING I—I 99 OTHER <br /> V.TANK LEAK DETECTION <br /> _j 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIALMONITORING CI 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES � NO <br /> F� <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THh BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAMEDATE <br /> (PRINTED 8 SIGNATURE) a ,:7 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# I TANK# <br /> STATE I.D.# ® F= <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> • � �� 1 { � /�vul1 / B•RS <br />