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NIIIIII/ STATE OF CALIFORNIA Im p �• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> A' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT < 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E::] 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: p <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# // B. MANUFACTURED BY: v, <br /> C. DATE INSTALLED(MOIDAY/YEAR) /670 <br /> D. TANK CAPACITY IN GALLONS: ID DOC7 <br /> If <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL O 4 OIL B. C. 10UN UNLEADED REGULAR 3 DIESEL 0 6 AVIATIO OL <br /> A O 2 PETROLEUM O 80 EMPTY 1 PRODUCT O 10 PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED O 5 JET FUEL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN O 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 C.A.S.0: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E:ZV -(r-47-,- / <br /> A. TYPE OF F-] 11 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEMb Z S LE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE O B POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTurk) 0 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN 0 99 OTHER <br /> 1 RUBBER LINED O 2 ALKYD LINING 0 3 EPDXY LINING Q 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING UNLINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSIONPOLYETHYLENE WRAP O 2 COATING 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Z <br /> CATHODIC PROTECTION a 91 NONE O95 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 IFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A-V,24RESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A VSINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U i 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 STFFI W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A&A UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [--] 1 AUTOMATIC LINE LEAK DETECTOR L:] 2 LINE TIGHTNESS TESTING 0 3 MOLAR RINGINTERSTITIAL <br /> O N OTHER <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 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 0 91 NONE O 95 UNKNOWN 110 99 OTHER S <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <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 /> (PRINTED 6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD.# ! <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE �, Y 3f 4 <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 <br /> FORM B (1291) <br /> ` IVFOROMB Fis <br /> 7 � V <br />