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0 <br /> •,'.o-- <br /> f <br /> STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B ;Y� A*: <br /> s y/ 0 <br /> COMPLETE A SEPARATE FORM FOR TANK SYSTEM <br /> MARK ONLY F7 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM F7 2 INTERIM PERMIT F7 A AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 p <br /> DBA OR FACEITY NAME WHERE TANK IS INSTALLED: (l A # t 1 I 1=544 <br /> I. TANK DESCRIPTION comPLETE ALL ITEMS- SPECIFY IF UNKNOWN ( /` <br /> A. OWNER'S TANK L D.s i i t'l` 544-7— M B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MCMMY/YE LAR) Yt • D. TANK CAPACITY IN GALLONS:A <br /> ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> to REGULAR I-3DIESEL <br /> A. 1 MOTOR VEHICLE FUEL J 4 OIL 8. C. EDUNLEADED 6 AVIATION GAS <br /> 2 PETROLEUM @D EMPTY �Q 1 PRODUCT to PREMIUM 4 CaASAHOI 7 METHANOL <br /> UNLEADED 6 <br /> JET <br /> 3 CHEMICAL PRODUCT ® 95 UNKNOWN ® 2 WASTE ' 6 ® 2 LEADED 99 OTHERW) <br /> L(DESCRIBE IN ITEM D. BELO <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 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 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK ! 1 BARE STEEL 2 STAINLESS STEEL F7 3 FIBERGLASS A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE r-7 7 ALUMINUM 8 IW% METHANOL C,OMPATTBLE W/FRP <br /> (PrimaryTank) U 9 BRONZE C! 10 GALVANIZED STEEL az 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLNC LINING <br /> C.INTERIOR <br /> LINING n 5 GLASS LINING � 6 UNLINED � 95 UNKNOWN � w OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO_ <br /> D.CORROSION U 1 POLYETHYLENE WRAP Ci 2 COATING U 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTIDttC 91 NONE RZ95 UNKNOWN ® 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A Lf> 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 U 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&* UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR ® 2 LINE TIGHTNESS TESTING I i�U STITL4FNG ❑gp OTHER <br /> V.TANK LEAK DETECTION <br /> C 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> ER 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 OUANTITY OFI 3.WAS TANK FILLED WITH YES NO(� <br /> SUBSTANCE REMAINING GALLON 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 ^!',, .{�y ¢�1 DATE <br /> .I�RIN.TEG 8$ ATUFm 1.0 / ''�«7 •rI. (�' 1� �j/�L/ �� g , r <br /> LOCAL AG NCY USE ONLY THE STATE LD.NUMBER LS COM S F FOUR NUMBERS BELOW t�< ? <br /> . <br /> COUNTY# JURISDICTION# FACILITY It TANK#C90A <br /> STATE LD.# m � <br /> PERMIT NUMBER ( PERMIT APPROVED BYADATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FILE THIS FORM 'OCAL AGENCY IMPLEMENTING THE UNDERGROUN -^-,E TANK REGULATIONS <br /> FORM B (12.91) <br /> fdi00]MB-Rt <br />