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r.x...z".."^-"T'F" '4i'i& fi''s'3';' �r--'^._ •.,cy.;,fl, -w�*,.v ,+,,;.,.,,.,.... „�,..,,.,,,. .,_,,, _.:m._�, .:r••., ..r7-e„77 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W� , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> A <br /> •CSI II OR M'' <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />'i MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ERMANENTLY CLOSE PIEONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURETANK REMOVED V[!J <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / j� H <br /> w <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/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />'E ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1 PREMIUM UNLEADED E:] 4 GASAHOL ❑ 7 METHANOL <br /> 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN El2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELC)M <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> i <br /> l 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 F-] 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM [:] 95 UNKNOWN <br /> r <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />� MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> E.SPILL AND OVERFILL,BiC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <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 U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING 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 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 U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 MECHANICAL LINE LEAK ❑2 UNE TIGHTNESS [:]3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC LINE ❑5 AUTOMATIC PUMP a 99 OTHER <br /> DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN <br /> i <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK E::] 2 MANUAL INVENTRECONCILIATIONORY E:] 3 MONITORING VADOZE ❑ 4 GAUGINAUTOMATG MONITORING <br /> TANK [:]5 GROUND MONITORINGTER ❑6 ANNUALTESTING <br /> ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR El9 WEEKLY MANUAL ❑10 MONTHLY TANK F-195 UNKNOWN ❑ 99 OTHER <br /> MONITORING TANK GAUGING TESTING <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 1.ESTIMATED DATE LAST 4DIMY A R) / 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> b SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES [:] NO ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> TANK OWNER'S NAME DATE <br /> (PRINTED S SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Ip <br /> r COUNTY# JURISDICTION# FACILITY# TANK# i <br /> STATE 044 61j <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUf ION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM <br /> FORM B (6-95) <br /> SHOULD BE ACCOMPANIED BY A PLOT WILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIRGROUND STORAGE TANK REGULATIONS <br /> , <br /> 'e <br /> L- <br />