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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> c4 rron NJ o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT E:] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 1 L7 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: g / L , <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# R. MANUFACTURED BY: d <br /> C. DATE INSTALLED(MC/DAY/YEAR) 61 -3 D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. 0 la R ULAR 3 DIESEL 6 AVIATION GAS <br /> 4 GASAHOL <br /> 2 PETROLEUM 90 EMPTY PK <br /> 1 PRODUCT1IPPREMIUM 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE u ' UNLEADED EADED [::] 5 JET FUEL <br /> 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 K <br /> 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER a 95 UNKNOWN <br /> SYSTEM Q 2 SINGLE WALL 71 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100'36 METHANOL GOMPATIBLE W/FRP <br /> (Primary Tank) E 9 BRONZE ID 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER <br /> F7 1 RUR13ER LINED F-1 2 ALKYD LINING O 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING `y� 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING !`� <br /> IS LINING MATERIAL COMPATIBLE WITH 1003'. METHANOL? YES x <br /> NO— <br /> D.CORROSION 0 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION F7 91 NONE 95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV. PIPING INFORMATION CIRCLE A IFABQVEG UNDOR U IFUNDERGROUNO,BOTHIFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL 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)A 04 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING 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 Vi AUTOMATIC LINE LEAK DETECTOR [�] 2 LINE TIGHTNESS TESTING 3 MQNR ORININTERSTITIA <br /> [--] 99 OTHER <br /> V.TANK LEAK DET TION <br /> F 1 VISUAL CHECK a 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING X7 INTERSTITIAL MON ITCRING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATE A LAST S D(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? U <br /> THIS F RM NAS$EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINYEDA 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 B (12-91) 0 ' !_3 1:21 j FOR0¢348-1`16 <br />