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STATE OF CALIFORNIA -We �• °s <br /> STATE WATER RESOURCES CONTROL BOARD p .' <br /> UNDERGROUND STORAGE TANK PERMIT APP KATION • FORM B �� y: <br /> p Y/ <br /> COMPLETE A SEPARATE FORM FOR TANK SYSTEM o,"'°""� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON§IM <br /> ONE REM ❑ 2 INTERIM PERMIT I❑ d AMENDED PERMIT ❑ 8 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.s B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO'DAYIYEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK qMENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> A. g 1 MOTOR VEHICLE FUEL ❑ d OIL g, C 1a UNLEADED REGULAR 8 7 DIESEL El AVIATIONGAS <br /> r72 PETROLEUM ❑ BO EMPTY 1 PRODUCT � 10 PREMIUM d GASAHOL ❑ 7 METHANOL <br /> F73 CHEMICAL PRODUCT UNLEADED 5 JETFUEL <br /> ❑ 95 UNIWOWN ❑ 2 WASTE O 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOWO <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S 0: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PlimmyTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ d PHENOLIC LINING <br /> C.INUNI GR F75 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ W OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN Q 99 OTHER <br /> E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 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 U d FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELW/COATING <br /> A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANN-ED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESSTESRNG ❑ MON00RING ❑ 99 [HER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 90 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 C:] NO❑ <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 /> (MNTEO 8411"ATURE) 7 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW L— <br /> COUNTY x JURISDICTION A FACILffV 8 1 1 TA 8 <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BWDATE 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 STORAGE TANK REGULATIONS_ <br /> FORM B (12-91) �l( kQ'dTf tv/l <br /> BAi <br />