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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �•"`°""� <br /> MARK ONLY O 1 NEW PERMIT IID 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE REM 2 INTERIM PERMIT E] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: ilf�. <br /> jea <br /> C. DATE INSTALLED(MO/DAYA'EAR) I V3 71 <br /> D. TANK CAPACITY IN GALLONS: tvoz) <br /> IL TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. O S 1a REGULAR O 3 DIESEL <br /> ���,,ayyc��� UNLEADED 6 AVIATION GAS <br /> 2 PETROLEUM a 80 EMPTY y 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> Ik UNLEADED O 5 JET FUEL <br /> Q 3 CHEMICALPRODUCT Q 95 UNKNOWN O 2 WASTE ❑ 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(Al)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 ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER F--] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL �,.0 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK O 1 BARE STEEL 9V 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE ///� 6 POLYVINYL CHLORIDE O 7 ALUMINUM 71 8 100h METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) O 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O W OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING 77� 3 EPDXY LINING E—] 4 PHENOLIC LINING <br /> C.INTELINNOR F-15 GLASS LINING 0 6 UNLINED ISI 95 UNKNOWN � 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO_ <br /> D.CORROSION F-1 1 POLYETHYLENE WRAP E:] 2 COATING 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION 0 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 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 A U 1 SUCTION kUjl 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 5 UNKNOWN A U W OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(P(iC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 ST LW/COATING <br /> A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 5 UNKNOWN p U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING ❑ 3 INIEHSTITAL <br /> MONITORING [::] 99 OTHER <br /> V.TANK LEAK DETECTION <br /> VISUAL CHECK INVENTORY RECONCILIATION O 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATERMONITORING <br /> TANK TESTING 7 INTERSTITIAL MONITORING E] 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 WITH YES NO 0 <br /> SUBSTANCFILLED <br /> E REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN C MPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTEn a SIGNATUREI �t) O S' /J <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 7 D 7 <br /> STATE LD.# <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> PERMIT NUMBER amPERMIT APPROVED BYIDATE P9RMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. /\�+ <br />