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eeoun � <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> V COMPLETE A SEPARATE FORM FOR EAC SANK SYSTEM -� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 25110 151 IS S z71� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.x B. MANUFACTURED BY: <br /> C. DATE INSTALLED Y/YEAR) D. TANK CAPACITY IN GALLONS: O <br /> ILT KC ENTS IFA-11SMARKED.00MPLETEITEMC. <br /> 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. G AUNLEA ED 3 DIESEL ❑ g AVIATIONGAS <br /> 2 PETROLEUM A PREMIUM 4 GASAHOL <br /> ❑ 3 CHEMICALPRODUCT 95 EMPTY ❑1�1/IPRODUCT 0 2 LEA <br /> UNLEADED 99 OTHER JET L(DESCRI�IN7ITEM 0. ELOM <br /> 95 UNKNOWN 2 WASTE 2 LEADED <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 ALLTHAT APPLIES IN BOX <br /> A. TYPE OF ❑�/y_�'/DOUB ALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM LIA GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> R. TANK <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING A ❑ 3 XY LINING E::] 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 BSS LINING ❑ 6 UNLINED UNKNOWN ❑ W OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO_ <br /> 0.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR 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 /> S. CONSTRUCTION A U / SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 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 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESSTESTING ❑ 3 MONRORINGL ❑99 OTHER <br /> TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> N\ ❑ 8 TANK TESTING ❑ 7 IN ERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ <br /> SUBSTANCE REMAINING GALLONS I INERTMATERIAL7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT,s' <br /> APPLICANT'S NAME DATE <br /> :X=-7^ � <br /> (G9INTEOaSIGNATUREI {///_� <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO <br /> �f i COUNTY x <br /> JURISDICTIObl# FACILITY x TANK# L 9 <br /> STATELDA <br /> vLTL <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE P TEXPI ONDATE <br /> FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOROMB N <br />