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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 F7 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOS I <br /> ONE ITEM a 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# +' B. MANUFACTURED BY: 0 vi pis <br /> C. DATE INSTALLED(MO/DAYNEAR) ('71tD. TANK CAPACITY IN GALLONS: 2 000 <br /> ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A ® 1 MOTOR VEHICLE FUEL 4 OIL8. C. Q la REGULAR <br /> 3 DIESEL 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY ® 1 PRODUCT tb PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN a 2 WASTE a 2 LEADED 0 <br /> 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED k -S Il` C.A.S.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 0 95 UNKNOWN <br /> SYSTEM a 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> B. TANK 1 BARE STEEL a 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE El 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE a 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYO LINING 3 EPDXY LINING F7 4 PHENOLIC LINING <br /> C.INTERIOR F7 5 GLASS LINING 6 UNLINED 7 95 UNKNOWN F7 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100'/ METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER q <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) I ! OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) ( I <br /> IV.PIPING INFORMATION CIRCLE A IFA13OVEG DOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A SUCTION A V2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A 0 2 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©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 INAOTo, RING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> a 1 VISUAL CHECK .4K] 2 INVENTORY RECONCILIATION a 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING `f7 7 INTERSTITIAL MONITORING 91 NONE a 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 E NO <br /> SUBSTANCE REMAINING LONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, N Tg T BE F MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME . DATE <br /> (PRINTEDE SIGNATURE) 7Av Ao <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE 4RUMBERS BEL W <br /> COUNTY# JURISDICTION# F'R61L1Lw# TANK# DO5 <br /> STATE I.D.# m <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> 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 <br /> FORM B (12.91) • FORD0348•R6 <br /> o �SS�d <br />