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777.7-111 <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. "a"" R <br />/Y <br />MARK ONLY 1 NEW PERMIT r7 <br />3 RENEWAL PERMIT <br />❑ 6 CHANGE OF INFORMATION <br />7 PERMANENTLY CLOSEDON I <br />ONE ITEM Q'`2 INTERIM PERMIT Q <br />4 AMENDED PERMIT <br />Q 8 TEMPORARY TANK CLOSURE <br />8 TANK REMOVED <br />w <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED:, <br />t <br />2 STAINLESS STEEL <br />3 FIBERGLASS <br />1- TANK DESCRIPTION rOMPI FTP Al I ITEMS _ <br />SPPCIFV IF mitiii[fviti <br />3 POLYVINYL CHLORIDE (PVC) A CF4 <br />7 STEEL W/ COATING A U <br />A U 95 UNKNOWN A U <br />FIBERGLASS PIPE <br />8 100% METHANOL COMPATISLEWIFRP <br />99 OTHER <br />A. OWNER'S TANK 1. D. # <br />B. MANUFACTURED BY: <br />C. DATE INSTALLED (MO/DAY/YEAR) w s <br />D. TANK CAPACITY IN GALLONS: 10,400 <br />ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. <br />A 1 MOTOR VEHICLE FUEL E:]lk 4 OIL <br />1 DOUBLE WALL <br />1�❑-'�2 <br />C. a REGUL R E:]❑ 3 DIESEL 6 AVIATION GAS <br />4 GASAHOL <br />F72 PETROLEUM a 80 EMPTY <br />1 PRODUCT <br />b PREMIUM ❑ 7 METHANOL <br />❑ UNLEADED F75 JETFUEL ❑ <br />❑ 3 CHEMICAL PRODUCT Q 95 UNKNOWN <br />2 WASTE <br />2 LEADED 99 OTHER (DESCRIBE 1N 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 OF13Q <br />1 DOUBLE WALL <br />1�❑-'�2 <br />O 3 SINGLE WALL WITH EXTERIOR LINER <br />E::]95 UNKNOWN <br />SYSTEM <br />SINGLE WALL <br />❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) <br />❑ 99 OTHER <br />TUU 2 DOUBLE WALL A U <br />❑ 1 BARE STEEL <br />2 STAINLESS STEEL <br />3 FIBERGLASS <br />_ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />3 POLYVINYL CHLORIDE (PVC) A CF4 <br />7 STEEL W/ COATING A U <br />A U 95 UNKNOWN A U <br />FIBERGLASS PIPE <br />8 100% METHANOL COMPATISLEWIFRP <br />99 OTHER <br />.� <br />MATERIAL <br />❑ 5 CONCRETE <br />F-] 6 POLYVINYL CHLORIDE <br />a 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE W/FRP <br />(PrimaryTank) <br />❑ 9 BRONZE <br />10 GALVANIZED STEEL <br />E-] 95 UNKNOWN <br />❑ 99 OTHER <br />❑ 1 RUBBER LINED <br />O 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C.INTENIOR <br />❑ 5 GLASS LINING <br />'1 ,,6 UNLINED <br />-WITH <br />� 95 UNKNOWN <br />1::199 OTHER <br />LINGIS <br />LINING MATERIAL COMPATIBLE 100% METHANOL? <br />YES NO— <br />D. CORROSION <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />3 VINYL WRAP <br />W4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION F-]91 NONE <br />95 UNKNOWN <br />Q 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />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 <br />A U <br />1 SUCTION <br />A' PRESSURE A U <br />3 GRAVITY A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />TUU 2 DOUBLE WALL A U <br />3 LINED TRENCH A U 95 UNKNOWN A 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 2 STAINLESS STEEL A U. <br />A U 6 CONCRETE A U <br />A U 10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC) A CF4 <br />7 STEEL W/ COATING A U <br />A U 95 UNKNOWN A U <br />FIBERGLASS PIPE <br />8 100% METHANOL COMPATISLEWIFRP <br />99 OTHER <br />D. LEAK DETECTION <br />3 INTERSTITIAL <br />1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESI&TESTING ❑ MONITORING <br />❑ 99 OTHER <br />V. TANK LEAK DETECTION <br />❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION F-]3 VADOZE MONITORING, F-]4 AUTOMATIC TANK GAUGING -]5 GROUND WATER MONITORIN( <br />❑ 6 TANK TESTING` 7 INTERSTITIAL MONITORING F-]91 NONE 95 UNKNOWN ❑ 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATEY,I T {1ST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES NO <br />i lam{ 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 S 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.# <br />PERMITNUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATIQAI DATE y, <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. <br />FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />.FORM B (12-91) <br />• ..r �w' 7 � FOR00348-R6 <br />L „4 <br />J <br />�t.�r .. ....,:.. .:._.c�1"'"`': s'Y`y►',s4 �9+.,n..i�e°>5..',-:uslibl�Nt�a...:aoi,"71�'^"/'.-'�+fi.t�iti±5.7" ui' :,;"..;;a^1MiMliS<.:'.f..:._ - rt.rYL <br />