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STATE OF CALIFORNIAN ..... <br /> STATE t <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 O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE /O <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O B TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.• 13 1 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A. I7CI 1 MOTOR VEHICLE FUEL O 4 OIL B. C. laREGULUNLEADAR <br /> `�' 3 DIESEL 6 AVIATIONGAS <br /> 2 PETROLEUM O 80 EMPTY x1 PRODUCT lb PREMIUM u 4 GASAHOL O 7 METHANOL <br /> O3 CHEMICALPRODUCT O 95 UNKNOWN 'O 2 WASTE LEADED Ej 99 OTHER (DESCRIBE IN ITEM D. BELOW)O 5 JET FUEL <br /> 2 <br /> O <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <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 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM O 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL 0 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE = 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primer)Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN E] 99 OTHER <br /> Q5 GLASS LINING 6 UNLINED ❑ <br /> 1 RUBBER LINED 2 ALKYD LNJING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING O � O 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION = 5 CATHODIC PROTECTION O 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 IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE 1 SUCTION APRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTK)N U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A 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 6 100% 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 ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> F1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED ATE LME (MO/DAV/VR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> YES NO 0 <br /> SUBSTANCE REMAINING GALLONS INERT MATER IAL? <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 /> (PRMTED431GNRNREI DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I.D.# <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> ST AAP <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 arTo <br /> FORMS (12 � <br /> 91) �UJ..�A <br /> 2 i r� 73 FOR00]/fiR6` <br />