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'E40Jn � <br /> STATE OF CALIFORNIA r �t <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "� �o <br /> r I ,r '.a y. I a <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �""°""�� <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED SY: <br /> C. DATE INSTALLED(MOA)AYNEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. vv <br /> A 1 MOTOR VEHICLE FUEL 4 OIL B. C taREGULARUN UNLEADED O 3 DIESEL 6 AVIATIONGAS <br /> 0 2 PETROLEUM E:] 80 EMPTY 1PRODUCT 1bAIOED O 5 ASAHOL 0 7 METHANOL <br /> UNLEADED <br /> 3 CHEMICAL PRODUCT 0 95 UNKNOWN O 2 WASTE O 2 LEADED 0 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF O 1 DOUBLE WALL3 SINGLE WALL WITH EXTERIOR LINER D 95 UNKNOWN <br /> SYSTEM O 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK D 1 BARE STEEL IN 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE8 POLYVINYL CHLORIDE O 7 ALUMINUM 0 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) O 9 BRONZE Q GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 LKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING � 6 U LINED O 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL? YES_ NO— <br /> D.CORROSION F-] 1 POLYETHYLENE WRAP [::] 2 COAG O 3 VINYL WRAP a 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODICPROTECTION 0 91 NONE O95 UNKNOWN a 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIUNDERGROUND,BOTH IFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUR A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE W L 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 S EL A U 3 POLYVINYL CHLORIDE(PVC)A 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 PROT TION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TG TNESS TESTING O 3 INT STIT <br /> MONITORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> I VISUAL CHECK Q 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITO NG 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING <br /> F7-,1 <br /> TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.EST MATED DATE LAST USED(MO/DAV/Vfl) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS WAS, <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 a 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 BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FO HAS BEEN F��� <br /> \/(O^/ 9 <br />