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STATEOFCAUFORNIA <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 PERMIT3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED ON SITE <br /> ❑ <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑IS INSTALLO ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK 09 <br /> l ornfav) d <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/OAViY'EAR) D <br /> -Ei D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 ISMARKED,COMPLETE ITEM C. <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. ❑ 1a HNUULAR 3 DIESEL <br /> ❑ 2 PETROLEUM ❑ LEADED <br /> 00 EMPTY ❑ 1 PRODUCT C ❑ 1b PREMIUM DIESEL <br /> 7GAAH <br /> LEADED ❑ 6 AVIATION GAS <br /> ❑ 3 CHEMICAL PRODUCT ❑ B5 UNKNOWN ❑ 2 WASTE UNLEADED ❑ ❑ 7 METHANOL <br /> ❑ 2 LEADED ❑ ESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> C.A.S.4: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THATAPPLIES INBOXD <br /> A <br /> . ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> ❑ 95 UNKNOWN <br /> ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> ❑ 6 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM <br /> ❑ 6 100% METHANOL COMPATIBLE W/FRp <br /> k) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING <br /> C.INTERIOR ❑ 4 PHENOLIC LINING <br /> UNING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP <br /> ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 0.5 UNKNOWN <br /> ❑ 88 OTHER <br /> IV.PIPING INFORMATION CIRCLE A WABOVE GROUND OR U IF UNDERGROUND.BOTH IFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE a U 3 GRAVITY <br /> A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH <br /> A U 95 UNKNOWN p 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 9 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL <br /> A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [:12 LINE TIGHTNESS TESTING 3 IEqS IAL ❑ <br /> W OTHER <br /> MONRORIND <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE <br /> ❑ BS UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DAT L &USE (MO/DAY/VR) 2.ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING 3.WAS TANK FILLED WITH <br /> L! GALLONS INERT MATERIAL? YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO <br /> APPLICANTS NAME THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> (PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE LD.# ® <br /> COUNTY JURISDICTION# FACILITY# TANK# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE <br /> PERMIT EXPIRATION DATE <br /> FORM 9 (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> 1 FORu' 1 ry <br />