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STATE OFCAUFOPNIA <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 1 NEW PERMIT _I 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION \ ,O 7 PERMANENTLY :-'�O ON SITE <br /> ONE ITEM 2 INTERIM PE RM;T A AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE ry� ! TANK REMC\'c. <br /> DBA OR FACILITY NAME WHERE TANK IS INS, E0. u— <br /> I. TANK DESCRIPTION COMPLETE,C: SPECIFY IF UNKNOWN <br /> A. OWNER'S TANKLD.. B. MANUFACTUFED BY: IG�O <br /> i <br /> C. DATE INSTALL D(MOCAYNEAR) V , I D. TANK CAPACITY IN GALLONS: bO <br /> ILTANKCONTENTS IFA-u6MAR�:D,ti'_E cli EM c. <br /> 1 MOTOR VEHICLE FUEL B. O, 1A REGULAR 3 DIESEL f �V.I-JN GAS <br /> A. _ ` � UNLEADED 8 GASOHOL <br /> 2 PETROLEUM _ �,EM PTY ' 1 PRODUCT 1D PREMIUM L T Vc"AhOL '� <br /> !' O UNLEADED O 5 JET FUEL <br /> 3 CHEMICAL PRODUCT r UNKNOWN 2 WASTE 2 LEADED O W OTHER (DESCRIBE 'N _M J. SELOW) <br /> D. IF(A.I)ISNOTUARKED, ENTER NAME U S.S ONCE STORED C.A.S.t: <br /> III. TANK CONSTRUCTION MARKDti ,'CN-Y!NSOXES A,B,ANDC.AND ALLTHAT APPLES 1550%D AND <br /> A. TYPE OF <br /> 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> -- <br /> SYSTEM 2 SINGLE WALL _ A SECONDARY CONTAINMENT (VAULTEDTANK) O W OTHER <br /> I BARE STEEL 2 STAINLESS SiEI 3 FIBERGLASS O A STEELCLAD WIFIBERGLASS RE'v+-7c0PLSTC <br /> B. TANK = <br /> MATERIAL =1 5 CONCRET-E 6 POLYVINYL CHLC;10E O 7 ALUMINUM O B 10PR METHANOL COMPATISL <br /> (Prim.ryT,nk) ❑ 9 BRCNZE 10 GALVANIZED S---EL 95 UNKNOWN O W OTHER <br /> 1 RUBBER LIN" 1 2 ALKYD LINING 3 EPDXY L!N,NG O A PHENOLIC LINING <br /> C.INTERIOR n 5 GLASS LINING _I 6 UNLINED -E -/95 UNKNOWN a 99 OTHER <br /> l <br /> LINING <br /> !SSL!NAG MATERIAL CCM=Ca_ W'TH 1001: METHANOL? YES_ NO— <br /> D.CORROSION ❑ ' POLYETHYLENE WRA= _I 2 COATING ❑ 3 VINYL WRAP O A FIBERGLASS REINFORCED P.15-` <br /> PROTECTION � 5 CATHDDICPPO"EC"JN 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CON-A:%V -.AS'ALLED(YEAF OVERFILL PREVEN70N EOUIPMENT INSTALLED(YEA <br /> IV.PIPING INFORMATION CIRCLE A .-kzC.'E GROUND OR U IF L'NDE RGROUNO,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A§71 SJC71CN A U 2 PRESSURE A U 3 GRAVITY A U N OTHER <br /> B. CONSTRUCTION A U 1 SINGLE W'A:L A U 2 DOUBLE WALL A U 3 LINED TRENCH U 95 UNKNOWN A U 9J c--:R <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STE LW/COATING A U 6 100x6 METHANOL CDM-A I6LEW/FRP <br /> PROTECTION A U 9 GALVANIZED S'EEL A U 10 CATHODICPR07ECT ION 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR D 2 UNE TIGHTNESS TESTING ❑ 34ONRORNG ❑99 OTHER <br /> V.TANK LEAK DETECTION -/ <br /> 1 VISUAL CHECK 2 INVENTORY REO.^%CILIATK)N 3 VADCZE MONITORING A AUTOMATIC TANK GAUGING Q 5 GROUND WA`R MONITORING <br /> C 6 TANK TESTING O 7 INTERSTITIA!9CN;7ORING G 91 NONE ❑ 95 UNKNOWN O W OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTM m <br /> AST S D(MO;DAV/Y R) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES r: N0 <br /> SUBSTANCE REMAINING GALLONS INERT MATERUL? L� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE B T OF M KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> 1 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY I JURISDICTION I FACIL FIY I �--�--�TANK I I� <br /> STATE I.D.# m � I I 1__L_ll__� <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT E%PIRATK)N DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORME (1291) ��`� <br />