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STATE OFCALIFORMA soos`e' <br /> STATE WATER RESOURCES CONTROL BOARD �+ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM. <br /> EDBAOR <br /> LY L-� 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> M 1 2 INTERIM PERMIT d AMENDED PERMIT O 7 PERMAN TLV C <br /> L I� 8 TEMPORARY TANK CLOSURE O 8 TANK R MOVED <br /> ACILITY NAME WHERE TANK IS INSTALLED: G e .I <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.a 7 <br /> B. MANUFACTURED BV: �// Ltn /.0 <br /> C. DATE INSTALLED(MO/DAYNEAR) b C D. TANK CAPACITY IN GALLONS: .9 L,.�L <br /> II. IANKC INIFWS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> A. - 1 MOTOR VEHICLE FUEL O d OIL B. O 1a REGULAR _ <br /> 2 PETROLEUM O BO EMPry 1 PRODUCT C ESEL <br /> UNLEADED d GASAHOL I- a AVIATION GAS <br /> O Ib PREMIUM L_17METHANOL <br /> F 13 CHEMICAL PRODUCT 0 95 UNKNOWN O 2 WASTE O 2 UNLEADED rElI 5 JETFUEL <br /> D. IF IA.1)IS NOT MAgKED, ENTER NAME OF SUBSTANCE STORED U OTHER (DESCRIBE IN I1EM D. BELOW) <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALL THAT APPLIES IN BOX DAND E <br /> A. TYPE OF El I/tlOUGLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER <br /> � !� � O 95 UNKNOWN <br /> SYSTEM _ -b 2 SINGLE WALL 0 d SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER_ <br /> B. TANK L-� I BARESTEEL 2 STAINLESS STEEL a 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL L 1 5 CONCRETE L-] e POLYVINYL CHLORIDE �71NUM a 8 100X. METHANOL COMPATIBLEW/FRP <br /> (DrimaryTenk) -� 9 BRONZE O IO GALVANIZED STEELWN O W OTHER <br /> I RUBBER LINED I 2 ALKYD LININ4 PHENOLIC LINING <br /> G <br /> 5 GLASS LINING U <br /> LJ 3 XY LINING -1 <br /> C.INTERIOR I 6 UNLINED LINING I C 5 UNKNOWN l 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100. METHANOL7 YES__ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION Q 91 NONE O 85 UNKNOWN F gg 0T7{Eq <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) - <br /> OVERFILL PREVENTION EOUIPMENTINSTALLED(YEAR)_ <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 'A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE lA U 3 GRAVITY A U 99 OTHER av' B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN <br /> A U 99 OTHER <br /> C. MATERIAL AND A U 1 BASE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING <br /> PROTECTION A U B 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC <br /> A U 95 UNKNOWN p U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING AL - - <br /> _-I --�NONRORMG 1 99 OTHER <br /> 11' rTANK LEAK DETECTION <br /> \1 r, 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> I_j 8 TANK TESTING n T INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN <br /> 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATEDA EL ST USED(MO/DAV/Y��1I�9S 2'ESTIMATEDOUANTITVOF <br /> SUBSTANCE REMAINING _ _GALLONS 3 WASINERT MATERIALTANK FILLED IIH <br /> JYES L I NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME <br /> (PRINTED a SIGNATURE) DATE } <br /> / 2- <br /> 60V <br /> L� <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> 6O NTYN JURISDICTION,# FACILITY# LANK 9CD <br /> STATE LD.# LJ d' z _ <br /> - - '- APPROVED <br /> PERMIT NUMBER PERMIT B /DATE PERWTEXPIRATION DATE <br /> THIS FORM MUST RE ACCOMPANI'Dlz b �..1 <br /> BY A PERMIT APPLICATION-FORM A,UNLESS A CURREP; -FORMA HAS Of EN FILED. <br /> ORMB (I2�9p FILE THIS FORM WITH THE�4L AGENCY IMPLEMENTING THE UNDERGROUND STnAh4, 'ANK REGULATIONS > <br /> T <br />