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_ T <br /> STATE CF CALIFORNIA P` .•., <br /> STATE WATER RESOURCES CONTROL BOARD 'NN <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B V <br /> � to <br /> COMPLETE A SEPARATE FORM <br /> ;;;���..FOR EACH TANK SYSTEM. <br /> ,,, <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# 0 B. MANUFACTURED BY: <br /> vv -T' <br /> C. DATE INSTALLED(MO/DAY/YEAR) 1-I Q" D. TANK CAPACITY IN GALLONS: <br /> II.TANK W16TENTS IFA•11SMARKED,COMPLETE ITEMC. <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. C• 1aUREGULAR NLEADED 3 DIESEL 6 AVIATION GAS <br /> Q 2 PETROLEUM 80 EMPTYPRODUCT 1b PREMIUM 4 GASAHOL <br /> 7 METHANOL <br /> F7 3 CHEMICAL PRODUCT 95 UNKNOWN2 WASTE 2 LEADED D 5 JET FUEL <br /> 99 OTHER (DESCRIBE IN ITEM D. BELOW; <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> C. <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E M1!� �F,� �j z!3.t <br /> A. TYPE OF 4RU' DOUBLE WALL D 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM El 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK E- ' BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 1003: METHANOL COMPATIBLE WlFRP <br /> (primaryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING ❑ 3 PDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR N5 GLASS LINING Q 6 UNLINED 95 UNKNOWNEl 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION D 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION L b CATHODIC PROTECT0N a 91 NONE 95 UNKNOWN 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 A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLEWIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 16 CATHODIC PROTECTION A(ID6 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [-�] 1 AUTOMATIC LINE LEAK DETECTOR E:] 2 LINE TIGHTNESS TESTING 3 INTRSTITIA7 <br /> MONITORING L-]99 OTHER <br /> V.TANK LEAK DETECTION <br /> 17 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> A TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES E] NO I--- <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT <br /> APPLICANTS NAML <br /> {PRINTED a SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I,D.# COUNTY# JURISDICTION# FACILITY# TANK# <br /> I� <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 ����C � <br /> FORM B (12-91) 111 <br /> / ! FOR0034B-R6 <br />