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0 • s,O�N [.g <br /> STATE OF CALIFORNIA A tiA <br /> P <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B d Z- <br /> 1 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: d r_-:::. t <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1,D.# r B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYIYEAR) r �I D. TANK CAPACITY IN GALLONS: l 0 <br /> IIJANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B.'y� C. UNLEA1a REGULAR ❑ 3 DIESEL 6 AVIATIONGAS <br /> A PETROLEUM 60 EMPTY 1�J 1 PRODUCT 1bPREMI�MD ❑ 4 GASAHOL ❑ 7 METHANOL <br /> 7"� - UNLEADED ❑ 5 JET FUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 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.A <br /> IIL 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ E <br /> 99 OTHR <br /> B. TANK {{�� <br /> i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS L] 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL I_I 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP <br /> IPrirmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING LX6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO_ <br /> Q CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 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 IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION 61 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND AU BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U4 BERGLASS PIPE <br /> CORROSION A U 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 A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL <br /> MONITORING ❑ 99 'OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK X2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING I❑ 5 GROUND WATER MONITORING <br /> 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> 10, <br /> VL TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOI !Y 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ N <br /> THIS ORM NAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED B 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.# LL <br /> PERMIT NUMBER 'PERMIT APPROVED BYIDATF PERMIT EXPIRATION DATE <br /> FORM B (7-911 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, ` <br /> :� �� FOR6034R-R <br />