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la6U <br /> CCS^ <br /> +_ STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVEDold <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ee <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> B. MANUFACTURED BV: G <br /> A. OWNER'S TANK I.D.i <br /> C. GATE INSTALLED(MDDAY/YEAR) <br /> D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-11SMARKED,CDMPLETEITEMC. El la REGULAR �/3 DIESEL O 6 AVIATION GAS <br /> i MOTOR VEHICLE FUEL O 4 OIL B. O- UNLEADED o 4 GAsAHOLPREMIUM <br /> O <br /> A O 2 PETROLEUM 80 EMPTY � PRODl1CT a 1bUNLEADED Q 5 JETFUEL T METHANOL <br /> 0 3 CHEMICALPRODUCT F__j 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW] <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED <br /> C.A.S.is <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA.B.AND C,AND ALLTHAT APPLIES IN BOX <br /> �1_DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN <br /> A. TYPE OF —199 OTHER <br /> SYSTEM IJ 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) <br /> O 1 BARE STEEL 2 STAINLESS STEEL 5�3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL <br /> (Primary Tw*) O 9 BRONZE O 10 GALVANIZED STEEL F__j 95 UNKNOWN 0 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING F-1 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING UNLINED 0 96 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION 0 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP Ej��FISERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION O 91 NONE O 95 UNKNOWN O 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U S5 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) 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 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 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING MONOORI GL 99 OTHER <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING �INTERSTITIAL MONITORING E] 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES 0 NO O <br /> T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> CrnOUNTY# JURISDICTION# FACILITY# �TANK# <br /> .# JI Syc.-e.2PS <br /> STATE I.DJ / C L L 1 L-LOW <br /> PERMIT NUMBER PERMIT APPROVED BV/DATE // 6_ PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FOR0034BA1 <br />