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STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD 3,off v o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ?o <br /> / <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY / NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATK)N O 7 PERMANENTLY CLOSED <br /> ONE REM INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IQ Q <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.9 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MODAY/YEAR) D. TANK CAPACITY IN GALLONS: l�O <br /> ILTANKCONTENTS FA-11SMARKED,COMPLETE ITEMC. <br /> A i MOTOR VEHICLE FUEL O 4 OIL B. C to REGULAR O 3 DIESEL g AVIATION GAS <br /> UNLEADED o 4 GASAHOL L] 7 METHANOL <br /> O EMIUM <br /> 2 PETROLEUM a BO EMPTY1 PRODUCT lb <br /> bUNLEADED 6 JET FUEL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED H 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORE C.A.3.#: <br /> III. TANK CONSTRUCTI N MARK ONE ITEM ONLY IN BOXES A,R ANDC,AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 LE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGL WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> O 1 RAREST = 2 STAINLESS STEEL 0 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK g POLYVINYL CHLORIDE 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL 5 CONCRETE <br /> (PrinuryTalk) O 9 BRONZE 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> 0 1 RUBBER LINED 2 ALKYD LIN WG O 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING 6 UNLINED = 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE 100-h METHANOL? YES_ NO— <br /> CO <br /> 1 POLYETHYLENE WRAP O COATING 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION Q 91 NE O96 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEA OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUft, A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WA A U 3 LINE TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STE A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 6 ALUMINUM A U 6 CONCRETE U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECT A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNE TESTING 0 7 MONITORING Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION a 3 VADOZE MONITORING AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING F7 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK C OSURE INFORMATION <br /> 1.ESTIMATE USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBS TAN CE REMAINING GALLONS I INERTMATERIAL7 YES O NOa <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 /> IPRINTE0661GNANRE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION III FACILITY# TANK# UUT <br /> STATE I.D.# "I I i I I1 /I 11:71101 ::1 <br /> PERMIT NUMBER I PERMIT APPROVED BY/DATE 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 <br /> S�TyORAAGE TANK REGULATIONS <br /> FORM B (12-91) `/ �� ' /' �� Y_^ 1 L/fld FORatt11BR6 <br />