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STATE OF CALIFORNIA *400 cam* <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �" <br /> „ y.� , 1 00 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM „o".�� <br /> MARK ONLY O 1 NEW PERMIT F7 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 6 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 I.D.# 'lp� !"� B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) .40�. �' D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A O 1 MOTOR VEHICLE FUEL 0 4 OIL 8. C ❑ la REGULAR <br /> 3 DIESEL 6 AVIATIONGAS <br /> O SAHOL <br /> 2 PETROLEUM O 80 PTV O 1 PRODUCT O 1b PREMIDM O 5 JETFUEL E::] 7 METHANOL <br /> UNLEA <br /> O 3 CHEMICALPRODUCT 95 UNKNOWN O 2 WASTE O 2 LEADED O 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 MARKONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOXDANDE <br /> A. TYPE OF 0 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 1-1 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL F-1 3 FIBERGLASS O 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL I7 5 CONCRETE O B POLYVINYL CHLORIDE a 7 ALUMINUM O 8 100°% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) O 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN F7 99 OTHER <br /> ❑ 1 RUBBER LINED 2 ALKYD LINING XY LINING F—] 4 PHENOLIC LINING <br /> LINING <br /> C.INTERIOR O 5 GLASS LINING O e UNLINED 95 UNKNOWN O 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING O 3 YL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION O 91 NONE 95 UNKNOWN 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 / 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®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 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100°% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING 3 <br /> MONITORING D N OTHER <br /> V.TANK LEAK DETECTION AGM <br /> 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION [_] 3 VADOZE MONITORING [—] 4 AU ATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING 0 91 NONE , 95/UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO <br /> SUBS TAN CE 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 /> APPLIT'S NAME DATE <br /> IPRIMEO dCANSIGNATURE] <br /> LOCAL AGENCY USE ONLY THE STATE 1.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE LDA <br /> COUNTY# JURISDICTION# TANK# <br /> PERM IT NUMBER Pt RM IT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR001BR5 <br />