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60VA P <br /> � STATE OF CALIFORNIA W P�. <br /> STATE WATER RESOURCES CONTROL BOARD s' ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� �: <br /> I„ o' <br /> COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. ,.°AH.� <br /> MARK ONLY 0 1 NEW PERMIT [:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT a S TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 07—1 14J <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: v <br /> ILTANK NTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A. <br /> 1 MOTOR VEHICLE FUEL O 4 OIL B. C. Q 18 REGULAR <br /> 3 DIESEL S AVIATKINGAS <br /> O 2 PETROLEUM O 80 EMPTY 1 PRODUCT O 15PREMI91 4 JET FUEL O 7 METHANOL <br /> UNLEADED Q 5 JET FUEL <br /> 3 CHEMICALPRODUCT O 95 UNKNOWN 02 WASTE O 2 LEADED O 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 <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL 0 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F7 5 CONCRETE F7 8 POLYVINYL CHLORIDE O 7 ALUMINUM B 100% METHANOL COMPATIBLE WlFRP <br /> (P(mary Tank) 9 BRONZE O 10 GALVANIZED STEEL Ej 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING O 6 UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH /OD%METHANOL? VES_ NO <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION O 91 NONE O 96 UNKNOWN O 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 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 a CONCRETE A U 7 STEEL W/COATING A U 9 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION L:J 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING O 3 INTERSTITIAL gg OTHER <br /> MONITORING D <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK F-1 2 INVENTORY RECONCILIATION F-] 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> e TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDQUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES O NO 0 <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 /> 1PRINTED851GNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD.# 5 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (v90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORXm S-R4 n <br />