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STATE OF CALIFORNIA q <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICAT10N - FORM B an ;° <br /> CIls l]X N•� <br /> COMPLETE A SEPARATE FORM FOR E21! K SYSTEM. <br /> MARK ONLY �' 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT CLOS - <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REM ED /C <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D. B. MANUFACTURED BY: (( C- <br /> C. DATE INSTALLED{MO1DAYfYEAR) E C D. TANK CAPACITY IN GALLONS: Do J Ga J4 <br /> 11.TANKCO TENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. -' C. FFIaUNLEADED REGULAR 3 DIESEL g AVIATIONGAS <br /> A. 4 GASAHOL <br /> 2 PETROLEUM 80 EMPTY ✓ 1 PRODUCT ❑ 75UNEA5 JET FUEL <br /> IDED ❑ 7 METHANOL <br /> 3 CHEMICAL PROOUCT 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN 1TEM D. BELOW) <br /> 0. 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,B,AND C,AND ALLTHAT APPLIES IN BOX D AND€ <br /> A. TYPE OF r DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM d 2,SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 1010% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED2 KYO LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D,CORROSION ❑ 1 POLYETHYLENE WRAP = 2�COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION [:!g'•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 IZ SUCTION' A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U '1J SINGLE CL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A UA U 2 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 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> 17111. <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 9 MONITORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK2 INVENTORY RECONCILIATION 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 96 NONE ❑ 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1,ESTIMATED DATE LAST USED(1000 YIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES a NO ❑ <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> {PRINTEO 6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER!S COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# -roe 7 -0 <br /> STATE I.D.# ! 7F F- / 7 NFT <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE BEAM IT 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. <br />