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STATE OF CALIFORNIA c" <br /> STATE WATER RESOURCES CONTROL BOARD s�P 1. ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B j k o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ep"�`� <br /> MARK ONLYNEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY ED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVE <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: row O i V <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 74S �G <br /> A. OWNER'S TANK 1.0.# 2 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYIYEAR) 117-7D. TANK CAPACITY IN GALLONS: OQ <br /> II.TANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ laREGULAR <br /> FADED 4 DIESEL L 0 6 AVIATIONGAS <br /> O 2 PETROLEUM O 80 EMPTY �• 1 PRODUCT � 1bPREMUM <br /> UN EAIDED F-] 5 JETFUEL 7 METHANOL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED 0 99 OTHER (DESCRIBE IN ITEM D. BELOW) <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 ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> B. TANK F-] / BARE STEELIli^ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F7 6 POLYVINYL CHLORIDE 7 ALUMINUM 0 8 1009k METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> O i RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%. METHANOL? YES_ NO— <br /> D.CORROSION 7� 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION yj 5 CATHODIC PROTECTION O 91 NONE O95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEMTYPE A U 1 SUCTION A )2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A(d)II SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 It> 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 Q 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 0 5 NONIfORING O99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAOOZE MONITORING Q4 AUTOMATIC TANK GING O 5 GROUNOWATERMONITORIN <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN F;gl 99 OTHER S1 <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E NO 0 <br /> SUBSTANCE REMAINING GAL N INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, DT BES O Y KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED a SIGNATURE( <br /> LOCAL AGENCY USE ONLY V THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR N BERS ELOW <br /> COUNTY# JURISDICTION# kACIL U TANK# <br /> STATE I.D.# 3 <br /> PERMIT NUMBER CtACVT—/o <br /> PERMITAPPROVE PERMIT EXPIRATION DATE / <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILEW�FO <br /> ROBM8 R5 <br />