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• Re <br />STATE OF CALIFORNIA • ^. �A6'""" `O, <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B :�� y: <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �""°""�� <br />MARK ONLY ❑ <br />1 NEW PERMIT E <br />3 RENEWAL PERMIT <br />4 <br />5 CHANGE OF INFORMATION <br />O <br />7 PERMANENTLY CLOSED ON SIT[ <br />ONE ITEM ❑ <br />2 INTERIM PERMIT O <br />4 AMENDED PERMIT <br />2 STAINLESS STEEL <br />6 TEMPORARY TANK <br />CLOSURE <br />O <br />8 TANK REMOVED O� <br />DBA OR FACILITY NAME <br />WHERE TANK IS INSTALLED: <br />-7--31 <br />5. SSC <br />c+efx <br />10 GALVANIZED STEEL <br />pQ <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN <br />A. OWNERS TANK I. D. # <br />cp J <br />B. MANUFACTURED BY: <br />4 <br />3 DIESEL 6 AVIATION GAS <br />4 GASAHOL E_� 7 METHANOL <br />5 JETFUEL <br />99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />C. DATE INSTALLED (MO/DAWYEAR) <br />/ 5"1 O <br />D. TANK CAPACITY IN GALLONS: <br />B. TANK <br />Q�d <br />II.TANKCONTtNTS IFA -1 ISMARKED. COMPLETE ITEM C. <br />A 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />2 PETROLEUM 0 80 EMPTY <br />3 CHEMICALPRODUCT 0 95 UNKNOWN <br />B. <br />1 PRODUCT <br />2 WASTE <br />C. aURR EGULA D <br />❑ 1b PREMIUM <br />UNLEADED <br />❑ 2 LEADED <br />95 UNKNOWN <br />3 DIESEL 6 AVIATION GAS <br />4 GASAHOL E_� 7 METHANOL <br />5 JETFUEL <br />99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />2 SINGLE WALL <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 S. AND C. AND ALLTHAT APPLIES IN BOX <br />A. TYPE OF <br />E] 1 D BLE WALL <br />F-]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 />B. TANK <br />1 BARE STEEL <br />2 STAINLESS STEEL <br />O 3 FIBERGLASS <br />0 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC <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 />95 UNKNOWN <br />99 OTHER <br />CORROSION <br />O 1 RUBBER LINED <br />0 2 ALKYD LMING <br />r7 3 EPDXY LINING <br />4 PHENOLIC LINING <br />C. INTERIOR <br />0 5 GLASS LINING <br />2r_6 NLINED <br />O 95 UNKNOWN <br />O 99 OTHER <br />LINING <br />A U <br />10 CATHODIC PRO ECTION <br />p 5 UNKNOWN A U <br />99 OTHER <br />D. <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? <br />YES_ NO— <br />AUTOMATIC LINE LEAK <br />D. CORROSION <br />O 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />Q 5 CATHODIC PROTECTIONNONE <br />❑ 95 UNKNOWN <br />99 OTHER <br />IV. PIPING INFORMATION_ r.IRCLE A IF ABOVFGROUND OR U IF IINOFRGROIINO ROTHIPAPPI IraRl F <br />A. <br />SYSTEM TYPE <br />SUCTION <br />A U <br />2 PRESSURE A U <br />3 GRAVITY A U 99 OTHER <br />B. <br />CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER <br />C. <br />MATERIAL AND <br />A U <br />i BARE STEEL <br />A U <br />2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE (PVC) A U <br />4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />6 CONCRETE A U <br />7 STEEL W/ COATING A U <br />B 10)% METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PRO ECTION <br />p 5 UNKNOWN A U <br />99 OTHER <br />D. <br />LEAK DETECTION <br />❑ 1 <br />AUTOMATIC LINE LEAK <br />DETECTOR 2 LINE TIGHTNESS TESTING O 3INTERSTITIAL <br />99 OTHER <br />MONITORING <br />V. TANK LEAK DETECTION <br />STANKCHECK 2 G INVENTORY RECONCILIATION 3 VAPOR MONITORING 4 AUTOMATICTANK GAUGING [—]5 GROUNDWATER MONITORING <br />6 TANK TESTING 0 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN O 99 OTHER <br />1. ESTIMATED DATE LAST USED (MO/DAV/YR) 2. ESTIMATED QUANTITY OF ISUBSTANCE REMAINING GALLONS I 3. WASINERT MATERIAL TANK FILLED I? YES NO <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 />IPRINTEO d SIGNATURE) <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY# JURISDICTION# FACILITY# TANK# ,Svr,Qr2.3 <br />STATE LD.# r3l_�] 9 2 z <br />PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE —S —2,5,17 0 <br />FORM B (9 90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. <br />• /1/// FOPOma�) <br />