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7 � <br /> A, STATE OFCWFORMA . ••~I,>t 1� <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 7 3 RENEWAL PERMIT S CHANGE OF INFORMATION \—O 7 PERMANENTLY C.-.'SED ON SITE <br /> r ONE REM 2 INTERIM PERMIT 7 A AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVE- <br /> DSA OR FACILITY NAME WHERE TANK IS INSTALLED: (-, <br /> ` I. TANK DESCRIPTION COMPLETECLr-uS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.9 I III B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYMEAR) D. TANK CAPACITY W GALLONS: OO <br /> ILTANKCONTENTS IFA.IISMARKED.-J 'P E-I7EMC. <br /> I MOTOR VEHICLE FUEL A OIL B. C. 1A REGULAR <br /> UNLEADED 3 DIESEL 1 9 AVATKM'GAS <br /> A. <br /> _ 0. EMPTY �fiC l I PRODUCT IO PREMIUM A µOL r " W-'ANOL <br /> 2 PETROLEUM <br /> _ 7— UNLEADED S JETFUEL L <br /> CI 3 CHEMICAL PRODUCT 95 UNKNOWN ED 2 WASTE 2 LEADED8 99 OTHER (DESCRISE N eM D. BELOW <br /> O. 1;(A.1)ISNOTMARKED. ENTER NAME OC SJSS'ANCE STORED C.A.S.S: <br /> .. III. TANK CONSTRUCTION MARK ONE cu ONLY IN BOXES A,B.AND C.AND ALLTHAT APPLIES IN BOX D AND <br /> - ,A. TYPE OF U I DOUBLE WALL I 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 1 A SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK L� t BARE STEEL -' 2 STAINLESS STEEL 13 FIBERGLASS � A STEELCUO W/FIBERGlA55 RE'vPCRCEO PLASTIC: <br /> MATERIAL �' 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM I 190% METHANOL COMPATIBLE R CRP <br /> (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED S-EL 95 UNKNOWN 99 OTHER <br /> J 1 RUBBER LINE.,- 2 ALKYD LINING O 3 EPDXY LINING A PHENOLIC LINING <br /> C.INn 5 GLASS LINING <br /> LINING <br /> i 6 UNLINED -x/95 UNKNOWN O 99 OTHER <br /> — — <br /> IS LKNG MATERIAL COVPAT B.E W--,Hl 1W% METHANOL? YES_ NO_ <br /> t� <br /> D.CORROSION =� 1 POLYETHYLENE WRA= 2 COATING 3 VINYL WRAP O A FIBERGLASS REWFORCED P.AS-G <br /> PROTECTION 5 CATHODIC PRO-EC7-C% 91 NONE �0 95 UNKNOWN D 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CON?ANVENS:NS'ALLED(YEAR OVERFILL PREVENTION EOUIPMENT INSTALLED(YEA <br /> IV.PIPING INFORMATION CIRC-IE A :AiDVEGROJNOORUIFUNDERGROUND,BOTH IFAPPLICABLE <br /> A. SYSTEMTYPE A371 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> a� <br /> B. CONSTRUCTION I U 1 SINGLE WCL A U 2 DOUBLE WALL A U 3 LVED TRENCH Ay,UA5 UNKNOWN A U W C=ER <br /> C. MATERIAL AND A U I 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 L W:COATING A U I 100% METHANOL COM=ATIBLE W.RP <br /> 01111, PROTECTION A U 9 GALVANSD S-EL A U 10 CATHODIC PROTECTION A 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION O1 AUTOMATIC LINE LEAK D'er CTOR E2 LINE TGHiNESSTESTING 1UNROAWG �99 OTHER <br /> `V.TANK LEAK DETECTION `may <br /> C I V3UAL CHECK lJ 2 INVENTORY R- .ON ED 3 VAOCZ-n MONITORING yl A AUTOMATICTANKGAUGING a 5 GROUND WA-;WON$-.ORNG <br /> 6 TANK 1ES-.&G a 7 INTERSTITIALVCN.IOR!•G ❑ 91 NONE 95 UNKNOWN a 99 OTHER <br /> a- VI.TANK CLOSURE INFORMATION <br /> 1.ESTIVT LATE LAST"S D(VOMAY,v RI 2 ESTIMATEJOLANT7Y OF I 3,WAS TANK FILLED WITH Y NO . <br /> SUSSTANCEREVA\:NG GALLONS INERTMATER.AL7 ES <br /> r THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE B T OF M4 KNOWLEDGE, 1S TRUE AND CORRECT <br /> APPLICANTS NAV1ME )n //1J,../ b `Ly, ,1 r�I �}J� A DA1TE <br /> r LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> CTOUNTY 6 JURISDICTION 6 FACILITY 6 - TANK I <br /> STATE I.D.# W <br /> PERMIT NUMBER I PERMIT APPROVED 6YIDATE PERMIT EXPIRATION 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 /> II-'CAM 6 (1291) - fORa"y9AY <br />