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0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND 'STORAGE TANK PERMIT APPLICATION- FORM B <br /> / n -51�e o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY a 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED /) <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 3 CS, <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS•• SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.1i ' B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYIYEAR) �+ D. TANK CAPACITY IN GALLONS: �. <br /> Il.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. >< MOTOR VEHICLE FUEL � 4 OIL B. C. la REGULUNLEADAR <br /> E] 3 DIESEL � 6 AVIATION GAS <br /> 2 PETROLEUM 60 EMPTY X1 PRODUCT 1b PREMIUM D 4 GASAHOL ❑ 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE2 LEADED 99 <br /> 5 JET FUEL <br /> 99 OTHER (DESCRIBE IN ITEM D. BELOW} <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STOHED C A S <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.R,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF D 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E�:] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) LIJ 99 OTHER <br /> B. TANK 1 RARE STEEL F7 2 STAINLESS STEEL a 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM B 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED a 2 ALKYD LINING E] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR N 5 GLASS LINING { I 6 UNLINED 0 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLES WITH 100% METHANOL? YES NO <br /> — <br /> 0.CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTVC <br /> PROTECTION 5 CATHODIC PROTECTION91 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 IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U FIBERGLASS PIPE <br /> CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U B 100°/ METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN <br /> A U 99 OTHER _ <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 31 ER AT <br /> MONITORING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> Ej 1 VISUAL CHECK +�17 <br /> 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANKGAUGING � 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIM TED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES E�] NC <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&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 I.D.# <br /> PERMIT NUMBER 'PERMIT APPROVED BYIDATE 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 <br /> FORM 9 (12-91) 0 0 FORD034B4 <br />