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• Gsouace <br /> C STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a rs <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 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT F-] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: //o3 S10764"In 00q r's <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.ar I B. MANUFACTURED BY: Nkeor <br /> C. DATE INSTALLED(MO/DAY/YEAR):2-d[ D. TANK CAPACITY IN GALLONS: O <br /> IL TANK CONT S IFA-1 IS MARKED,COMPLETE ITEM C. <br /> UNLEADED <br /> A. -1 MOTOR VEHICLE FUEL � 4 OIL g, C. � 1aEGULAR3 DIESEL E-] 6 AVIATION GAS <br /> 0 2 PETROLEUM a 80 EMPTY 1 PRODUCTREMIUM D 4 GASAHOL 0 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE E 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 1 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER lil 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) F-1 99 OTHER <br /> B. TANK F 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F-� 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM F--] 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) E::] 9 BRONZE F--] 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION F--] 1 POLYETHYLENE WRAP 0 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 0 91 NONE a F-] 95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 1�L_ OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) Z- <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION 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 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1D0% 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 E] 2 LINE TIGHTNESS TESTING IN I hKti I I I IAL <br /> 2r MONITORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK [::] 2 INVE ORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 05 GROUND WATER MONITORING <br /> FE-- 6 TANK TESTING <br /> INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN E] 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEb t]UANTITY OF 3.WAS TANK FILLED WITH YES [::] NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <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 <br /> (PRINTED 6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# ef}rv121) <br /> STATE I.D.# 3 y �m 1 58' 7 11 S 12 17110 11 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> • � FOR00308•R5 <br />