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0da <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION=FORM B a 0 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT F--] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C-"—V V,0 V, 2-7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> C.A <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. Wj laREGULAR LEADED 3 DIESEL 6 AVIATION GAS <br /> X UN <br /> F--] 2 PETROLEUM E::] 80 EMPTY 1 PRODUCT E::] 4 GASAHOL lbPREMIUM 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT F--j 95 UNKNOWN O 2 WASTE E:] 2 LEADED E] 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX D AND E <br /> A. TYPE OF x 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER E--] 95 UNKNOWN <br /> SYSTEM � 2 SINGLE WALL � 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK F--] 1 BARE STEEL E 2 STAINLESS STEEL K] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 7 5 CONCRETE F-1 6 POLYVINYL CHLORIDE [--] 7 ALUMINUM 8 100% METHANOL COMPATIBLEW/FRP <br /> (Primary Tank) 9 BRONZE E] 10 GALVANIZED STEEL E:] 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING F--] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR F--] 5 GLASS LINING 6 UNLINED 96 UNKNOWN 99 OTHER <br /> LINING p <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 E::] 91 NONE O 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)-0 10 <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 76 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@ 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1001% METHANOL COMPATIBLEW/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 [:] I AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING 3'MNoTENRrrSoTRTjNFA,3' [::]99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK E& 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING F-] 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE E] 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF rl�l3 S TANK FILLED WITH YES [::] NO <br /> SUBSTANCE REMAINING G LLO INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF f!2LWf Y,AY070ATHE BVG)(MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME DATE <br /> (PRINTED&SIGNATURE) oAqkf--) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE F NUM 1ERS BELOW,)I <br /> COUNTY# JURISDICTION# FAC111T**--' TANK# <br /> STATE I.D.# FTI Il I FT-F] <br /> PERMIT NUMBER I 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) F011003413-R6 <br />