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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> id> <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D. Z B. MANUFACTURED BY: LU/ 49A- <br /> C. DATE INSTALLED(MO/DAYNEAR) / D. TANK CAPACITY IN GALLONS: d O <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A ^�'1 MOTOR VEHICLE FUEL 0 4 OIL B. C. 1eREGULAR 3 DIESEL <br /> UNLEADED 8 4 GASAHOL O 6 AVIATION GAS <br /> O 2 PETROLEUM O SO EMPTY twq-1 PRODUCT O 1b PREMIUUNLEADED 0 5 JET FUEL 7 METHANOL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED a 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x: <br /> III. TANK CONS'TTRR{UCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF !y1 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O95 UNKNOWN <br /> SYSTEM IJ 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) E-] 99 OTHER <br /> O 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL Q 5 CONCRETE O 8 POLYVINYL CHLORIDE 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> 0 1 RUBBER LINED 2 ALKYD LINING 0 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING 6 UNLINED 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VE9X- NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION Q 91 NONE O95 UNKNOWN 99 OTHER ��p� <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)_LL/¢_ <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> S. CONSTRUCTION A U 1 SINGLE WALL p®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)'C.Y'4 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 bZl AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING ❑ 3 IT11STIT111, 9g OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING SiC4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> O 6 TANK TESTING7 INTERSTITIAL MONITORING 0 91 NONE O 95 UNKNOWN 0 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO 0 <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 /> (PRINTED aSIGNATURE <br /> ) 74 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK#60�z <br /> STATE I.D.# m161 p & a 1 151O <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE 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 FI <br /> FORMB R5 <br />