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• • GSOV S <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD w <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B -° <br /> COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM. ��`�°aN.• <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED h <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3co 7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# R v1. B. MANUFACTURED BY: E <br /> C. DATE INSTALLED(MO/DAY/YEAR) 3 D. T"NK CAPACITY IN GALLONS: 10, 000 ea IS <br /> ILTANKCONTENTS IFA-11SMARKED,COMPLETEITEMC. <br /> p of MOTOR VEHICLE FUEL F_� 4 OIL g, C � 1aREGULAR ADED 0 3 DIESEL 6 AVIATIONGAS <br /> 2 PETROLEUM 80 EMPTY II Y1 PRODUCT PREMIUM 0 4 GASAHOL 7 METHANOL <br /> "ttt��� UNLEADED a 5 JET FUEL <br /> 3 CHEMICAL PRODUCT 0 95 UNKNOWN 2 WASTE 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.#: DO (06 Ig <br /> III. TANK CONSTRUCT N 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 <br /> SYSTEM 2 SINGLE WALL F-1 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL 0 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL � 5 CONCRETE a 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM 8 1009/6 METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 0 9 BRONZE 0 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> ❑ 1 RUBBER LINED O 2 ALKYD LINING 0 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR a 5 GLASS LINING C ' UNLINED O 95 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 0 1 POLYETHYLENE WRAP [::] 2 COATING 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [::] 5 CATHODIC PROTECTION 0 91 NONE F-]95 UNKNOWN 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 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 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 /> IAL <br /> D. LEAK DETECTION [::] 1 AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING MONrroRING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK a 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING <br /> 6 TANK TESTING V7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.tSTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] NO D <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME �. DATE <br /> (PRINTED 8 SIGNATURE) n�n,n� 'w D/w 6 <br /> LOCAL AGENCY USE ONLY 1GTHE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# m d ptlLz <br /> PERMIT NUMBER PERMIT APPROVED BY TE PERMIT EXPI A IQN DAT <br /> 9pA <br /> FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> �8FO(%'RA/J0 <br /> 'IX34/8 RS <br />