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STATE OF CALIFORNIA �/ "�"•""•• i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> �f COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT D 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED / <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: � cQ/ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.a / s� S S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYA'EAR) ¢.• D. TANK CAPACITY IN GALLONS: 5-, D <br /> ILTANK ONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL O 4 OIL g, TE <br /> to REGULAR 3 DIESEL 6 AVIATIONGAS <br /> UNLEADEDO 2 PETROLEUM O 80 EMPTY 1 PRODU1b PREMIUM 4 GASAH0 7 METHANOL <br /> 3 CHEMICAL PRODUCT O95 UNKNOWN a 2 WASTE 2 UNLEADED O 5 JET FUEL a <br /> 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.R: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF E] ;,DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM Li EINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK 1 RARE STEEL 2 STAINLESS STEEL a 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE E] 7 ALUMINUM F7 8 100% METHANOL COMPATIBLE WiFRP <br /> (Primary Tank) 0 BRONZE 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 VKYD LINING F] 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED E `05J UNKNOWN O 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ll NO- <br /> D.D.CORROSION 1 POLYETHYLENE WRAP 2 COATING ❑ 33 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION 91 NONE O95 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 IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTK7N A 1 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 STEELW/COATING <br /> A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESSTESTING 3 99 OTHER <br /> MONRORING <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK X2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING O 91 NONE 0 95 UNKNOWN 0 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATE DTE ST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO O <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 <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 /> (PRINTEDA SIGNANRE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# I I I I I = U <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (12-91) <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATIQN-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS I lY <br /> FORODMB R6 <br />