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^�. o• <br /> SPATE OF CALIFORNIA � � <br /> STATE WATER RESOURCES CONTROL BOARD 3y �o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B :�� �a <br /> .ry <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM `"^o""'� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY Gj.�S �\ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REM <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 37 U/ I 1^ <br /> 1. TANK DESCRIPTION COMPLETE ALLITEMS- SPECIFYIFUNKNOWN (i <br /> A OWNERS TANK LD.# B. MANUFACTURED BY: V� <br /> C. DATE INSTALLED(MO(DAYIYEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CO NTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A. I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 11WEUNLEADED <br /> 3 DIESEL ❑ 6 AVIATIONGAS <br /> O 2 PETROLEUM ❑ 90 EMPTY �PR�IICT ❑ 1DPREMIUM A GASAHOL ❑ J METHANOL <br /> ❑ <br /> UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE N ITEM D. BELOW) <br /> D. IF(Al)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A&AND C.AND ALLTHAT APPLIES IN BOX <br /> 1 LE WALL 3 SINGLE WALL WITH EXTERIOR LINER <br /> A. TYPE OF ❑ ❑ 95 uNINowN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC - <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 IOD% METHANOL COMPATIBLE W/FRP <br /> (PnmuyTank) ❑ 9 BRONZE ❑ 10 GALVANEED STEEL1NKNOWN r7 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LNNG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C INLIN WIGR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES_ NO— <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEUNINOWN O 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE SUCTION PRESSURE A U 3 GRAVITY A 9B OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PMA U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 �W/COATING A U 9 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING E.3 MONOORN6 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑�AL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> 8 TANK TESTING ❑ 7 NTERSTRULMONRORING ❑ 9/ NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MDAOAY/YR) I 2.EST9AATED QUANTITY OF 1 WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL I YES ❑ NO❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> IomMm a m0KA1uAp DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY JURISDICTION# FACILITY# 3 TANK# Ql7I f, <br /> 13> . <br /> STATE LD.# /T',,uL W <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (9-9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR110fLW <br />