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tee° un e <br /> STATEOFCAUFORMA ` <br /> STATE WATER RESOURCES CONTROL BOARD i� ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B �e <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ��7❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED O� <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Cl p{ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNFAR) D. TANK CAPACITY IN GALLONS: 60 <br /> ILTANKCO S IFA-11S MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL ❑ 4 OILB. C. EGULAR �❑ 3 DIESEL ❑ 6 AVIATION GAS <br /> UNLEADED LTJ{ 4 GA3AHOL <br /> ❑ 2 PETROLEUM ❑ 90 EMPTY 1 PRODUCT O 1b PREMIUM ❑ 7 METHANOL <br /> UNLEADED ❑ 6 JET FUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.v: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEMSINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK / BARE STEEL F-12 STAINLESS STEEL [—] 3 FIBERGLASS [:j4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 1009: METHANOL COMPATIBLE W/FRP <br /> (PNmwyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED w OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE L 5 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION ACU 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 9 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AUNKNOWN A U N OTHER <br /> D. LEAK DETECTION [-] 1 AUTOMATIC LINE LEAK DETEC"1R LINE TIGHTNESS TESTING ❑ 31A10NRORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑(QCHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING E] 5 GROUND WATER MONITORING <br /> 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYlYR) 2.ESTIMATED OUANTITY 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 /> IPRINTEO4 SIGN.TORE1 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# eIQ a <br /> STATE LDAp 0 5 S 3 z I O&n # <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. a'+41 ryp <br /> } //!� FOR09MBR1 <br />