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STATE OFCALIFORMA . `i <br /> ° STATE WATER RESOURCES CONTROL BOARD '4. a, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION " FORM B �� �e <br /> `ten YI�...� C <br /> \ J: . <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM "�""�" <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O ; PERMANENTLY CLOSED ON SIT <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED D <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ? St <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.# 3 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: O <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. <br /> A. i MOTOR VEHICLE FUEL 0 4 OIL B. C 1aREGULAR UN <br /> UNLEADED 3 DIESEL 6 AVIATIONGAS <br /> 2 PETROLEUM O BO EMPTY I}[I 1 PRODUCT O 11DPREMIUM 4 GASAHOL O T METHANOL <br /> •--�c UNLEADED 5 JETFUEL <br /> O 3 CHEMICALPRODUCT 95 UNKNOWN 2 WASTE 2 LEADED O 0 OTHER (DESCRIBE IN ITEM D. BELOWI <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: <br /> III. TANK CONSTRUCTION ARK ONE ITEM ONLY IN BOXES A,8,ANDC.AND ALLTHAT APPLIES IN BOX D AND <br /> A. TYPE OF O 1DOUBLE W L 0 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM F-12 SINGLE WAL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE ; ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 8 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 0 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOL %.LINING <br /> C.INTERIOR 05 GLASS LINING <br /> LINING O 6 UNLINED O 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPA IBLE WITH 100% METHANOL; YES— NO_ <br /> D.CORROSION O 1 POLYETHYLENE WRAF--] 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODICPROTECTI [-] 91 NONE O95 UNKNOWN E—] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT IIISTALUED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFA OVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 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 A U 1 BARE STEEL A U2 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 ; STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION O 1 AUTOMATIC LINE LEAK TECTOR 0 2 LINE TIGHTNESS TESTING MONITORING E7199 OTHER <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK O 2 INVENTORY RECONCIL TION 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> O 6 TANK TESTING 0 ; INTERSTITIAL MONITORI G 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIM TEDDATE LAST U DMO/DAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL; YES O NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAMEDATE <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.# AR = ,—I -31111 " )f 7I <br /> PERMITNUMBER PERMIT APPROVED BV/DATE �'-- PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. t� <br /> 1 � - q3 FORaD>,Bu� <br />