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STATE OF CALIFORNIA �. <br /> STATE WATER RESOURCES CONTROL BOARD a _ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> C�[1F uw N� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL SED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> r <br /> I. TANK DESCRIPTION COMPLETE ALL'ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.N B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYIYEAR) -- D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> REGULAR <br /> A 1 MOTOR VEHICLE FUEL 0 4 OIL B. C. 1aUNLEADED 3 DIESEL 6 AVIATION GAS <br /> 4 GASAHOL <br /> 2 PETROLEUM � 80 EMPTY � 1 PRODUCT E] 16UN UNLEADED � 5 JET FUEL ❑ 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE E-] 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW! <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.IS <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF x 1 DOUBLE WALL F] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL F-1 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE O 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) E�] 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> F7 1 RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN � 99 OTHER <br /> LINING <br /> IS LINING MATERfAL COMPATIBLE WITH 1005 METHANOL? YES NO <br /> D.CORROSION 0 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION a 5 CATHODIC PROTECTION 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 U 1 SUCTION Ao PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL Ar`U 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) U FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A-U 6 100% METHANOL COMPATIBLE WFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 9 INTERSTITIAL <br /> 99 OTHER <br /> OF <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 0 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> L ESTIMATED DATLILAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO O <br /> J' I � i <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 8 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 /> PERMIT NUMBER 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 � <br /> FORM B (12.91) I 1"�'fq�1�Y FORD¢346-RS <br />