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• STATE OF CALIFORNIA • '""" y <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> ~ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 9 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o G oA1 AV ^ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) 17 D. TANK CAPACITY IN GALLONS: b �d <br /> II.TANK TENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL g, C 1a REGULAR n 3 DIESEL a e AVIATIONGAS <br /> UNLEADED IL-=11 4 GASAHOL <br /> 2 PETROLEUM Bp EMPTY 1 PRODUCT O lb PREMIUNLEAUM <br /> O 5 JET FUEL 7 METHANOL <br /> F 3 CHEMICAL PRODUCT 0 95 UNKNOWN O 2 WASTE 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 /> Z3 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,ANDC.AND ALLT14ATAPPLIES INBOX GANGS <br /> A. TYPE OF IO 11 DOUBLE WALL E:] 3 SINGLE WALL WITH EXTERIOR LINER O 85 UNKNOWN <br /> SYSTEM Ewj 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK BARE STEEL 0 2 STAINLESS STEEL 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F7 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED 2 ALKYD LINING E::] 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR r 5 GLASS LINING UNLINED 95 UNKNOWN 99 OTHER <br /> LINING / <br /> IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO <br /> D.CORROSION F] 1 POLYETHYLENE WRAP 2 COATING 0 INYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION r-1 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN O 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION cf> <br /> PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION 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 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 STEEW/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING 7 A 99 OTHER <br /> MONRORING <br /> V.TANK LEAK DETECTION <br /> ❑ 1 ISUAL CHEfK EZ2 INVENTORY RECONCILIATION a 3 VADOZE MONITORINGE] 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> I?f6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN 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 O 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 <br /> (PRINTED a SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FA&H;rf-# TANK# <br /> STATE IBMg ( ��flei� <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE A`� 9 9 <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) � • � „ y>, <br /> \v �ROttMBR6 <br />