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• 0 <br /> Souaces <br /> STATE OF CALIFORNIA PG <br /> STATE WATER RESOURCES CONTROL BOARD ;_ rs <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B At° <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT F--] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT p 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED o <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �g'� L� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) 5 7, D. TANK CAPACITY IN GALLONS: 47 <br /> s� <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C. <br /> la REGULAR <br /> 3 DIESEL El <br /> 6 AVIATION GAS <br /> A 0 2 PETROLEUM F-180 EMPTY 1 PRODUCT 1b PREMIUM D 4 GASAHOL Cl 7 METHANOL <br /> �ll UNLEADED 5 JET FUEL JJ <br /> 3 CHEMICAL PRODUCT F-1 95 UNKNOWN 2 WASTE 2 LEADED F-] 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 MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF li� <br /> DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLE WALL F-] 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F-] 6 POLYVINYL CHLORIDE F--] 7 ALUMINUM 8 100°/ METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL F--] 95 UNKNOWN 99 OTHER <br /> F-] 1 RUBBER LINED 0 2 ALKYD LINING F--] 3 EPDXY LINING F-] 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING 6 UNLINED F-] 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 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION 91 NONE �95 UNKNOWN F-] 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 4DP2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 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�93 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [�] 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL <br /> MONITORING D gg OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK �2 INVENTORY RECONCILIATION a 3 VADOZE MONITORING F] 4 AUTOMATIC TANK GAUGING E] 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE E:] 95 UNKNOWN 0 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 a NO D <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 /> APPLICANT'S NAME DATE <br /> (PRINTED 6$IGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I.D.# <br /> COUNTY# JURISDICTION# FACILITY# TANK# <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 FILEDP <br /> FOR00348-R6 <br /> i • <br />