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I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I. D. # If <br />B. MANUFACTURED BY: <br />C. a REGUL R 3 DIESEL 6 AVIATION GAS <br />lb <br />C. DATE INSTALLED (MO/DAY/YEAR) 23 <br />t <br />O <br />3 CHEMICAL PRODUCT 95 UNKNOWN <br />❑ <br />2 WASTE <br />2 LEADED 99 OTHERFUEL <br />(DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. A <br />2 STAINLESS STEEL <br />3 FIBERGLASS <br />T <br />B. TANK <br />MATERIAL <br />STATS OF CALIFORNIA <br />F-] 6 POLYVINYL CHLORIDE <br />❑-1 7 ALUMINUM <br />E�:] 8 100% METHANOL COMPATIBLE W/FRP <br />STATE WATER RESOURCES CONTROL BOARD <br />ib . <br />0 10 GALVANIZED STEEL <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B^� <br />O 99 OTHER <br />l< <� <br />F-1 1 RUBBER LINED <br />F7 2 ALKYD LINING <br />F--] 3 EPDXY LINING <br />a 4 PHENOLIC LINING <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />E] 5 GLASS LINING <br />MARK ONLY <br />�1 NEW PERMIT F7 <br />3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br />ONE ITEM <br />� 2 INTERIM PERMIT F7 <br />4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 8 TANK <br />REMOVED � , .Po <br />CMJ <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />%,Q i _ .07 .0 T.4ly . 4�i s' � - ►) <br />4 P-111,01 ' <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I. D. # If <br />B. MANUFACTURED BY: <br />C. a REGUL R 3 DIESEL 6 AVIATION GAS <br />lb <br />C. DATE INSTALLED (MO/DAY/YEAR) 23 <br />D. TANK CAPACITY IN GALLONS: <br />O <br />ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. <br />A. 1 MOTOR VEHICLE FUEL 4 OILB. <br />Ne 1 DOUBLE WALL <br />C. a REGUL R 3 DIESEL 6 AVIATION GAS <br />lb <br />2 PETROLEUM 0 80 EMPTY <br />1 PRODUCT <br />PREMIUM 4 GASAHOL 7 METHANOL <br />UNLEADED JET <br />3 CHEMICAL PRODUCT 95 UNKNOWN <br />❑ <br />2 WASTE <br />2 LEADED 99 OTHERFUEL <br />(DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. A <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A- R- AND C- AND ALL THAT APPLIES IN BOX D AND E <br />A. TYPE OF <br />Ne 1 DOUBLE WALL <br />F-] 3 SINGLE WALL WITH EXTERIOR LINER <br />95 UNKNOWN <br />SYSTEM <br />F-1 2 SINGLE WALL <br />Q 4 SECONDARY CONTAINMENT (VAULTEDTANK) <br />99 OTHER <br />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 />MATERIAL <br />F-] 5 CONCRETE <br />F-] 6 POLYVINYL CHLORIDE <br />❑-1 7 ALUMINUM <br />E�:] 8 100% METHANOL COMPATIBLE W/FRP <br />(PrimaryTank) <br />[::] 9 BRONZE <br />0 10 GALVANIZED STEEL <br />D 95 UNKNOWN <br />O 99 OTHER <br />INTERSTITIAL <br />MONITORING <br />F-1 1 RUBBER LINED <br />F7 2 ALKYD LINING <br />F--] 3 EPDXY LINING <br />a 4 PHENOLIC LINING <br />C. INTERIOR <br />E] 5 GLASS LINING <br />6 UNLINED <br />F7 95 UNKNOWN <br />E:] 99 OTHER <br />LINING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES>< NO— <br />D. CORROSION <br />F--] 1 POLYETHYLENE WRAP <br />2 COATING <br />[::] 3 VINYL WRAP <br />X4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />F-1 5 CATHODIC PROTECTION 0 91 NONE <br />0 95 UNKNOWN <br />E�] 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 />U <br />PRESSURE A U <br />3 GRAVITY <br />A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH <br />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 <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 04 <br />7 STEEL W/COATING A U <br />A U 95 UNKNOWN A U <br />FIBERGLASS PIPE <br />8 100% METHANOL COMPATIBLE W/FRP <br />99 OTHER <br />D. LEAK DETECTIONj <br />1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING ❑ 3 <br />INTERSTITIAL <br />MONITORING <br />❑ 99 OTHER <br />V. TANK LEAK DETECTION <br />1 VISUAL CHECK F-] 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING F--] 4 AUTOMATIC TANK GAUGING F--] 5 GROUNDWATER MONITORING <br />6 TANK TESTING X7 INTERSTITIAL MONITORING F-] 91 NONE [:] 95 UNKNOWN [:] 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATED T ST 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 a SIGNATURE) <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION It FACILITY # TANK # <br />STATE I.D.# lt <br />PERMITNUMBER PERMIT APPROVED 'Y/DATED 4 PERMITEXPIRATIQNDATE4 /i`i- <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) • � .� �.1 �./� ^"/ � FOR0030•116 <br />