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°;UR <br /> • STATE OF CALIFOFNA <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> Com' COMPLETE A SEPARATE FORM FORY6 TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 RMANENTLY LOSED ONSI E <br /> ONE ITEM 2 INTERIM PERMIT <br /> F-] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOV <br /> it 0 Lv no <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: i <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS <br /> II.TANK COTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> REGULAR IESEL <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. UNLEADED 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT b PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT O 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.7 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF 1 OUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM ly 2 INGLE WALL F-14 SECONDARY CONTAINMENT (VAULTED TANK) E] 99 OTHER <br /> 1 BARE STEEL F-] 2 STAINLESS STEEL F-] 3 FIBERGLASS Ej4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL 0 5 CONCRETE F-� 6 POLYVINYL CHLORIDE F--] 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTaok) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 5peAY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED 5 UNKNOWN Ej 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES <br /> D.CORROSION F-] 1 POLYETHYLENE WRAP 2 COATING ❑ 3 INYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION � 5 CATHODIC PROTECTION F 91 NONE 95 UNKNOWN E] 99 OTHER <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 U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> 1 BARE STEEL U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC A U 4 FIBERGLASS PIPE <br /> C. MATERIAL AND A U A (PVC) <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 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION E:l 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING Ej 3 INTERSTITIA <br /> NTERS I GL O 99 OTHER <br /> MONITV.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION F-] 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING E:l 91 NONE El 95 UNKNOWN 99 OTHER <br /> 1 VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE n <br /> (PRINTED 8 SIGNATURE) S <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> sOS COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD.# 10101 / 1p <br /> PERMITNUMBER % PERMIT APPROff D Y/ A PERMIT EXPIRATION DATE <br /> FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR00346•R4 <br /> /057 <br />