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STATECFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM, "'"""•o <br /> MARK ONLY 1 NEW PERMIT 7 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE REM r—I 2 INTERIM PERMIT A AMENDED PERMIT 8 TEMPORARY TANK CLOSURE U B TANK REM <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# S. MANUFACTURED <br /> C. DATE INSTALLED(MO/OAY/YEAR) b(-1I,,— 0, TANK CAPACITY IN GALLONS:- <br /> 11. <br /> ALLONSII.TANK Q&TENTS FAI IS MARKED.COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL j A OIL B, G to REGULAR 7 DIESEL <br /> UNLEADED '� 8 AVIATION GAS <br /> C 2 PETROLEUM SO EMPTY 1 PRODUCT ib PREMIUM a GASAHOL ❑ 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> S CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED <br /> go OTHER (DESCRIBE IN ITEM D. BELOW <br /> 0. IF(A1)LR NOT MARKED. ENTER NAME OF SUBSTANCE STORED h ao WlyC.A S a. <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF D DOUBLE WALL Q 7 SINGLE WALL WITH EXTERIOR LINER a % UNKNOWN <br /> SYSTEM SINGLE WALL a SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK IV I BARE STEEL 2 STAINLESS STEEL O FIBERGLASS A STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL i 5 CONCRETE 6 POLYVINYL CHLORIDE 'u 7 ALUMINUM B 100% METHANOL CCMPATI8LE W/FRP <br /> (PnmaryTmk) 9 BRONZE 10 GALVANIZED STEEL % UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 7 EPDXY LINING a PHENOLIC UNING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED % UNKNO 99 OTHER <br /> LINING — <br /> IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO <br /> D.CORROSION —' I POLYETHYLENE WRAP = COATING 7 VINYL WRAP A FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 7v91 NONE Q% UNKNOWN % OTHER <br /> E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF A80VEGERGROUNO.80TH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTI A U 2 PRESSURE A U 7 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION 4 U 1 SINGLE 4 U 2 DOUBLE WALL A U 7 LINED TRENCH A U % UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A 1 BARE STEM/ A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC)A U s FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U S 100% METHANOL CCMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATH0OICPROTECTION A U % UNKNOWN A U 9g OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC UNE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 7 MONITORING '—' 9# OTHER <br /> V.TANK LEAK DETECTIONF F-I QYK OY� <br /> 1 VISUAL CHECK LJ 2 INVENTORY RECONCILIATION 7 VADOZE.NONRORIN(9 ❑ 6 AUTOMATIC TANK GAUGING 5 ROUND WATER MONITORING <br /> ❑ 6 TANK TESTING F i 7 INTERSTITIAL MONITCAING 91 NONE % UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 7.WAS TANK FILLED WITH YES C 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 /> IPNRTEO s SK.NAN / <br /> I✓ <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 17 <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.* �s � 0 31 <br /> PERMIT NUMBER PERMIT APPROVED BY/OATE I PERMIT EXPIRATION DATE - <br /> I <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGIJLATIONS- <br /> FCRM 9 ;1291) - FOR60)1BA6 <br />