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SJU" C4 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 'o' <br /> 0 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY a 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CL7' ON )1;E <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOV <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ��r^or. 9 4 Z 7 5 <br /> I. TANK DESCRIPTION COMPLE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# S. MANUFACTURED BY:f1 QAkS <br /> C. DATE INSTALLED(MO/DAY/YEAR) Gj 8 D. TANK CAPACITY IN GALLONS: ; O <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C. XC la REGULAR <br /> 0 3 DIESEL 6 AVIATION GAS <br /> F7 2 PETROLEUM a 80 EMPTY ® 1 PRODUCT 0 1bPREM1UM 4 GASAHOL 7 METHANOL <br /> a 3 CHEMICAL PRODUCT 95 UNKNOWN a 2 WASTE [:] 2 UNLEADELED 0 a 99 JET L <br /> 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 <br /> F--"I 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 71 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 0 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS GI 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 1009/6 METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> F7 1 RUBBER LINED 2 ALKYO LINING a 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR a 5 GLASS LINING 6 UNLINED <br /> LINING F7 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING F7 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION a 5 CATHODIC PROTECTION a 91 NONE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) (ci 9 o 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 1 SUCTION A'U ;2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A 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 l@ 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 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 0 2 LINE TIGHTNESS TESTING 3 MONITORING [:]99 OTHER <br /> V.TANK LEAK DETECTION <br /> F 1 VISUAL CHECK ® 2INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 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 S TANK FILLED WITH <br /> SUBSTANCE REMAINING LLO INERT MATERIAL? YES NO <br /> r <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF Y,A T(?THE B T MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME 1 DATE <br /> (PRINTED d SIGNATURE) 'o n 4 ` <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE F R NUM ERS BELOW <br /> COUNTY# JURISDICTION# FACICt#*e—' TANK# S' <br /> STATE I.D.# 3H 1111 111 FLIoloz,-11011 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRAT16N 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) <br /> FOR00348-R6 <br /> a/� �v cesse� <br />