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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B � <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT ® 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSE. <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE L�YJ 8 TANK REMOVED <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. A6° MANUFACTURED BY: _ <br /> I <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> r ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> F- <br />` q 1 MOTOR VEHICLE FUEL 4 OIL B. C. la <br /> aUNLEADED REGULAR 3 DIESEL F-16 AVIATION GAS <br /> F 2 PETROLEUM 80 EMPTY 1 PRODUCT 1b PREMIUM D 4 GASAHOL I—l 7 METHANOL <br />(" UNLEADED 5 JET FUEL L JJ <br />' 0 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED F—] 99 OTHER(DESCRIBE 1N ITEM D. BELOWI <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> i <br /> Ill. 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 1 DOUBLE WALL F_� 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN l <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL F__] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> i MATERIAL 0 5 CONCRETE 6 POLYVINYL CHLORIDE Ej 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL [:] 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING F—] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING F-] 5 GLASS LINING 6 UNLINED 95 UNKNOWN ED <br /> 99 OTHER a <br />" IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> E ' F—] 1 POLYETHYLENE WRAP 0 2 COATING E:] 3 VINYL WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC ' <br /> D.CORROSION <br /> k PROTECTION 5 CATHODIC PROTECTION91 NONE 95 UNKNOWN E�] 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 t 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> N. CON$TRUCTKm` Ale 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A Up' 99 OTHER <br /> C. MATERIAL AND Adh 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 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 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 I MONITORING 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> a 1 VISUAL CHECK 0.2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VC.TANK CLOSURE INFORMATION <br /> F.ESTIMATED DATELAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF q 3.WAS TANK FILLED WITH YES NO <br /> ., SUBSTANCE REMAINING " GALLONS INERT MATERIAL? Fj <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND 00t?RE0T <br /> APPLICANTS NAME DATE <br /> (PRINTED&SIGNATURE) _ <br /> ,LCL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I°D.# m 1 :Fla <br /> �- <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> I� <br /> i 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 M <br /> FORM B (12-91) <br /> l ' ts <br />