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a�souA Fy ° <br />STATE OF CALIFORNIA ? ° <br />STATE WATER RESOURCES CONTROL BOARD 3 ,d <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />°�I FOR N•� . <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br />ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -;w Al, <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I. D. # 01 <br />B. <br />B. MANUFACTURED BY: <br />2 PETROLEUM 80 EMPTY <br />C. DATE INSTALLED (MO/DAY/YEAR) <br />i <br />D. TANK CAPACITY IN GALLONS: <br />12- j 00o <br />ILTANKCONTENTS IFA -1 IS MARKED, COMPLETE ITEM C. <br />A. b 1 MOTOR VEHICLE FUEL 4 OIL <br />B. <br />C. 1a REGULAR3 DIESEL 6 AVIATION GAS <br />4 GASAHOL <br />2 PETROLEUM 80 EMPTY <br />1 PRODUCT <br />1b PREMIUMEl 7 METHANOL <br />UNLEADED ❑ 5 JET FUEL <br />3 CHEMICAL PRODUCT E-1 95 UNKNOWN <br />2 WASTE <br />2 LEADED 99 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 <br />MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOXID AND E ��Ll�� b. F - <br />�'Z3 . YJ <br />A. TYPE OF <br />1 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />95 UNKNOWN <br />SYSTEM <br />2 SINGLE WALL <br />❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) <br />❑ 99 OTHER <br />SINGLE WALL <br />1 BARE STEEL <br />F-]2 STAINLESS STEEL <br />F-]3 FIBERGLASS <br />4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZED STEEL <br />A U <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC)A U <br />7 STEEL W/COATING A U <br />5 UNKNOWN A U <br />MATERIAL <br />5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />F-]95 UNKNOWN <br />99 OTHER <br />F-]1 RUBBER LINED <br />[:]2 ALKYD LINING <br />3 EPDXY LINING <br />F-]4 PHENOLIC LINING <br />C. INTERIOR <br />F-]5 GLASS LINING <br />F-]6 UNLINED <br />?�95 UNKNOWN <br />99 OTHER <br />LINING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES_ NO <br />D. CORROSION <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />95 UNKNOWN <br />99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND. BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A <br />_2 PRESSURE A U <br />3 GRAVITY A U 99 OTHER <br />B. CONSTRUCTION <br />A&l <br />SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A U 95 UNKNOWN p U 99 OTHER <br />C. MATERIAL AND <br />CORROSION <br />PROTECTION <br />A U <br />A U <br />A U <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZED STEEL <br />A U <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC)A U <br />7 STEEL W/COATING A U <br />5 UNKNOWN A U <br />4 FIBERGLASS PIPE <br />8 100% METHANOL COMPATIBLE W/FRP <br />99 OTHER <br />D. LEAK DETECTION <br />❑ 1 <br />AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING <br />❑ 99 OTHER <br />V. TANK LEAK DETECTION <br />❑ 1 VISUAL CHECK in 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br />y6 TANK TESTING F-] 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. WAS TANK FILLED WITH YES ❑ NO <br />SUBSTANCE REMAINING GALLONS 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 DATE <br />(PRINTED 8 SIGNATURE) <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY # TANK # <br />STATE I. D.# ? p JJ� <br />PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br />FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. <br />0 40 <br />FORO B -R5 <br />