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• SUR <br />STATE OF CALIFORNIA i' "'�"t <br />STATE WATER RESOURCES CONTROL BOARD 3� " <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY � 1 NEW PERMIT 0 <br />3 RENEWAL PERMIT <br />C. DATE INSTALLED(MO/DAYNEAR) -.J U ! <br />5 CHANGE OF INFORMATION <br />7 PERMANENTLY CLOSED ONSITE <br />ONE ITEM 2 INTERIM PERMIT ❑ <br />4 AMENDED PERMIT <br />❑ <br />6 TEMPORARY TANK CLOSURE <br />B TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />A <br />6�1 4 STEEL CLAD W! FIBERGLASS REINFORCED PLASTIC <br />O hi <br />❑ 5 CONCRETE <br />1. TANK DESCRIPTION r:r)MP1 FTF Al I rrs~Me _ <br />,zprriry IG I INICNnwN <br />B 100% METHANOL COMPATIBLE W/FRP <br />41114 -AAAI <br />Y <br />A. OWNER'S TANK I. D.0 2 <br />R. MANUFACTURED BY: I r <br />C. DATE INSTALLED(MO/DAYNEAR) -.J U ! <br />D. TANK CAPACITY IN GALLONS: <br />II_ TANK CONTENTS ICA_1I_CAAAQVPnrnM1ADICTCITMAn ems. . <br />A. 1 MOTOR VEHICLE FUEL 4 OIL <br />B.C. <br />3 DIESEL 6 AVIATIONGAS <br />UNLEADED <br />2 PETROLEUM BD EMPTY <br />1 PRODUCT <br />{{�—`—�� <br />❑ 16 PREMIUM U 4 GASAHOL �1 7 METHANOL <br />UNLEADED 5 JETFUEL �I <br />3 CHEMICAL PRODUCT 95 UNKNOWN <br />2 WASTE <br />2 LEADED 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 MAPK r]NF ITFAA nNl V IN Rf1YCC A R ANn!` AAIH AI I T AT AOo1 ICC 1 10 <br />A. TYPE OF <br />�1 DOUBLE WALL <br />F7 3 SINGLE WALL WITH EXTERIOR LINER <br />E:1 95 UNKNOWN <br />SYSTEM <br />❑ 2 SINGLE WALL <br />4 SECONDARY CONTAINMENT (VAULTED TANK) <br />❑ 99 OTHER <br />B. TANK <br />❑ 1 ®ARF STEEL <br />2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />6�1 4 STEEL CLAD W! FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />❑ 5 CONCRETE <br />6 POLYVINYL CHLORIDE <br />7 ALUMINUM <br />B 100% METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />9 BRONZE <br />10 GALVANIZED STEEL <br />95 UNKNOWN <br />99 OTHER <br />AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 I S I99 <br />MONITORING <br />1 RUBBER LINED <br />2 ALKYD LINING <br />3 EPDXY LINING <br />4 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />5 GLASS LINING <br />® 6 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 <br />YES— NO <br />D. CORROSION <br />❑ 1 POLYETHYLENE WRAP <br />2 COATING <br />3 VINYL WRAP <br />4�? 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION 91 NONE <br />95 UNKNOWN <br />0 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. PIPING INFORMATION <br />CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE <br />FACILITY # <br />A. SYSTEM TYPE <br />A 1 <br />SUCTION <br />Ad -2 PRESSUR_E"S A U 3 GRAVITY A U 99 OTHER <br />B. CONSTRUCTION <br />A U 1 <br />SINGLE WALL <br />U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />A U 1 <br />BARE STEEL <br />A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U <br />4 FIBERGLASS PIPE <br />CORROSION <br />PROTECTION <br />A U 5 <br />A U 9 <br />ALUMINUM <br />GALVANIZED STEEL <br />A U 6 CONCRETE A U 7 STEEL WICOATING A U <br />A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U <br />B 100% METHANOL COMPATIBLE W/FRP <br />99 OTHER <br />D. LEAK DETECTION <br />❑ 1 <br />AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 I S I99 <br />MONITORING <br />❑ OTHER <br />V. TANK LEAK DETECTION <br />0 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING t5� 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br />❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE E:l 95 UNKNOWN 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATED DATE LAST USED (MOIDAYIYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 r DATE _ <br />)PRINTE�851GNATURE) \ Qv Q_ �Q �.l n.`. S }7' r_ ��_ ^ <br />LOCAL AGENCY USE O"C..N..3YYLffY ,7THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW [� <br />STATE I. D.# <br />COUNTY # JURISDICTION # <br />FACILITY # <br />TANK # <br />Z <br />PERMITNUMBER <br />PERMIT APPROVED BYIDATE <br />ro 'f <br />I PERMIT EXPIRATION DATE <br />FORM B )7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. <br />0 0 <br />FOR00348-R5 <br />