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STATE OF CALIFORNIA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD ,. n <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 8 RENEWAL PERMIT [Ij5 CHANGE R INFORMATION <br /> 7 PERMANENTLY CLOSED TE <br /> ONE ITEM 2 INTERIM PERMIT � 4 AMENDED PERMIT D J <br /> 6 TEMPORARY TANK CLOSURE ' B TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (� 41-A l i <br /> I, TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> 1411:7 <br /> I I MANUFACTURED BY: n�i <br /> A OWNER'S TANK 1.D.N 1 `''� /'��'y <br /> t D. TANK CAPACITY IN GALLONS: IV�E%`, <br /> C. DATE INSTALLED(MOlDAY/YEAR) 1 -7 Z <br /> II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 6 AVIATION GAS <br /> C 1a REGULAR UNLEADED 3 DIESEL <br /> A. 1 MOTOR VEHICLE FUEL 4 Oft 9. lb PREMIUM UNLEADED 4 GASAHOL 7 METHANOL <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT �1 1C GIDGRADE UNLEADED 5 JET FUEL B M85 <br /> 95 UNKNOWN 2 WASTE uO 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW <br /> 3 CHEMICAL PRODUCT )) <br /> F0, IF .1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM D 95 UNKNOWN <br /> A. TYPE OF 4 SINGLE WALL IN A VAULT 99 OTHER <br /> SYSTEM 2 SINGLE WALL <br /> 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC <br /> B. TANK F-1 6 POLYVINYL CHLORIDE 7 ALUMINUM 6 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL � 5 CONCRETE <br /> (Primary Tank) 9 BRONZE Q 10 GALVANIZED STEEL a 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LIFTED = 2 ALKYO LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING OR 5 GLASS LINING <br /> E 6 UNLINED 95 UNKNOWN 99 OTHER <br /> � <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.EXTERIOR 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION gl NONE Ej <br /> 95 UNKNOWN 99 OTHER <br /> PROTECTION 5 CATHODIC PROTECTION <br /> SPILL CONTAINMENT INSTALLED(YEAR) LATOVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> E.SPILL AND OVERFILL,BtC, STRIKER PE YES NO DISPENSER CONTAINMENT YES NO <br /> DROP TUBE YES NO <br /> IV.PIPING IN CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING 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 /> A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> C. MATERIAL AND I <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W!COATING A U S 104% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> 1 MECtW1+fIGAL UNE LEAK 2 LINE TIfiHTNE55 u 3 CONTINUWS 1FiTERSTITIAt �4 ELECTRONIC UNE I�5 AUTOMATIC PUMP O 99 OTHER <br /> D. LEAK DETECTION � TESTING u MnMToa�Nc lEAx tYETEc1oR I sHUTmwN <br /> DETECTOR <br /> V.TANK LEAK DETECTION <br /> AUTOMAT <br /> OUND <br /> ANNUAL <br /> F-1 1 VISUAL CHECK <br /> 2 MANUALRECONCILIATION ENTORY 0 3 MONITORING 4 GAUGING IC TANK 5 MONITORING TER 6 TESTING <br /> TANK <br /> 7 <br /> MONITORING_OUINTERSTITIAL fl 8 SIR 9 TWANK GA ANNEAL 10 MESTINGONTHLY TANK 95 UNKNOWN 99 OTHER <br /> Vt.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO <br /> 1.ESTIMATED DATE LAST USED(MOIDAYIYR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,DATE S TRUE AND CORRECT <br /> TANK OWNER'S NAME z�st'J L <br /> �IVS1� s� ��'7II � 4 ICJ <br /> (PRINTED S SIGNATURE) p ,�i4c6iTJ 1V�' <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NU E IS C OSED OF THE FOUR NUMBERS BELOW TANK# <br /> COUNTY# JURISDICTION# FACILITY# <br /> STATE I.D.# + <br /> PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL N-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. PGROUND STORAGE TANUST BE COMPLETED KRREGULATIIO SNS THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH <br /> FORM B (6.95) <br />