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♦ 7 wp <br /> �i <br /> STATE OF CALIFORNIA c�s- <br /> STATE WATER RESOURCES CONTROL BOARD i♦'- <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W��. »° <br /> 1 <br /> Ow M�♦ <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 0 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 I.D.% ? B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) J D. TANK CAPACITY IN GALLONS: Z.D <br /> ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1aREGULARUNLEADED 03 DIESEL q GASAHOL 6 AVIATION GAS <br /> 2 PETROLEUM 0 80 EMPTY >4 1 PRODUCT �.1bUNLEADEDI0 5 JETFUEL T METHANOL <br /> O 3 CHEMICALPRODUCT Q 95 UNKNOWN 0 2 WASTE O 2 LEADED O 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 0 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> 1 BARE STEEL O 2 STAINLESS STEEL � 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL 0 5 CONCRETE O B POLYVINYL CHLORIDE O 7 ALUMINUM O B 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTank) 0 9 BRONZE 0 10 GALVANIZED STEEL 0 95 UNKNOWN 0 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING 6 UNLINED 0 95 UNKNOWN 0 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VE92C NO— <br /> D.CORROSION 0 i POLYETHYLENE WRAP 0 2 COATING 0 3 VINYL WRAP 15e, 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 0 91 NONE O95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) /94 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)J� <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION Ar—D <br /> A/� 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> A <br /> B. CONSTRUCTION A U 1 SINGLE WALL ® 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&4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T 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 1 AUTOMATIC LINE LEAK DETECTOR E 2 LINE TIGHTNESS TESTING 31610NITIAL <br /> RORING 0 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING 5C 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> 0 6 TANK TESTING 7 INTERSTITIAL MONITORING 0 91 NONE O 95 UNKNOWN 0 99 OTHER <br /> A.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO 0 <br /> SU85TANCE 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 8 SIGNATUR S �_ <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACT TANK%�Q <br /> STATE I.D.# 0 (o ! 6 a <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILE . <br /> FORMBA5 <br />