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• STATE OF CAUFORNA • •eeo YR e <br /> - .r( STATE WATER RESOURCES CONTROL BOARD ^� �' <br /> 'il/-"113r UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B 3"�� "y o <br /> COMPLETE A SEPARATE FORM FOR E ANK SYSTEM `�".o�.." <br /> MARK ONLY ❑ 1 NEW PERMITRENEWAL PERMIT <br /> ❑ 3 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM [-] 2 INTERIM PERMIT [:] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE <br /> B TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z S <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.a D/ <br /> B. MANUFACTURED BY: � IL <br /> C. DATE INSTALLED(MOIDAY/YEAR) �� <br /> D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A <br /> . / MOTOR VEHICLE FUEL ❑ 4 OIL. B. C ❑ 1a REGULAR Ian 3 DIESEL <br /> 2 PETROLEUM EMPTY ❑ 1 PRODUCT 16 NLEADE �J 6 AVIATION GAS <br /> 4 GASAHOL3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JETFUEL 7 METHANOL <br /> 2 LEADED9g OTHER (DESCgIBE IN ITEM D. BEL)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIESIN 80%D <br /> A. TYPE OF ❑,�-mUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> SYSTEM 0'2 SINGLE WALL ❑ 95 UNKNOWN <br /> ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 98 OTHER <br /> B. TANK ❑ 1 RE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS <br /> ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 5 CONCRETE <br /> ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED <br /> C.INTERIOR ❑ !,ALI('fD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN <br /> ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ING ❑ 3 VINYL WRAP <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 81 NONE ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> ❑B5 UNKNOWN ❑ " OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,80TH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE <br /> U 3 GRAVI A U 99 OTHER <br /> B. CONSTRUCTION A U 1 IN E A A U 2 DOUBLE WALL <br /> A U 3 LINED TRENCH A U 95 UNKNOWN A U 89 OTHER <br /> — <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC <br /> CORROSION A U 5 ALUMINUM A U ONCRETE ( IA U 4 FIBERGLASS PIPE <br /> PROTECTION A U 9 GALVANIZED STEEL I U 7 STEEL 5 UNKNOCOATINWN <br /> A U 9 100% METHANOL COMPATIBLE W/FRP <br /> A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p U 99 OTHER_ <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR � 2 LINE TIGHTNESS TESTING ❑ 3 MONRORINGL ❑ � OTHE <br /> V.TANK LEAK DETECTION <br /> FEE] <br /> VISUALCHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 ORMONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> TANK TESTING ❑ 7 INTERSTITIALMGNITGRING 91 NONE <br /> ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST U i D MO/OAYNR) 2.ESTIMATED SUBSTANCE QUANTITY <br /> REMAINING <br /> Q 3.WAg TANK FILLED WITH YES ❑ <br /> / GALLONS INERT MATERIALT 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COU L <br /> JURISDICTION# FACILITY# T <br /> STATE LD.# JJ ITI <br /> PERMIT NUMBER IT APPROVED BV/DATE © / <br /> PER MITEXPIRATI NDA <br /> FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> goFOR0031B.PA <br />