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w�y�UR eg c <br /> r <br /> STATE OF CALIFORNIA �r <br /> k <br /> STATE WATER RESOURCES CONTROL BOARD W�, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - 'FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> MARK ONLY <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: tp r <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.4 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYlYEAR) D. TANK CAPACITY IN GALLONS: <br /> 11.TANK qnTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a R LEADED H 3 DIESEL ❑ 6 AVIATION GAS <br /> A 4 GASAHOL ❑ 7 METHANOL <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1tUNLEADE <br /> 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.4r: <br /> III. TANK CONSTRUCTIO MARK ONE ITEM ONLY IN BOXES A,B.AND C.ANDALLTHATAPPLIES INBOX 0 <br /> ❑ 1 DOUBL ALL Cl 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A. TYPE OF 99 OTHER <br /> SYSTEM A❑ 2 SINGLE W L ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) <br /> 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC <br /> B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL ❑ 5 CONCRETE <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> I RUBBER LINED ❑ 2 ALKYD 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 TH 100% METHANOL? YES, NO— <br /> ❑ 1 POLYETHYLENE WRAP F-1COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROU OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 P SSURE A U 3 GRAVITY A U 99 OTHER <br /> 2 DO LE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAIN L SS STEEL A U 3 POLYVINYL CHLORIDE(AVC)A U 4 FIBERGLASS PIPE <br /> CORROSION p U 5 ALUMINUM A U 6 CONCRE A U 7 STEELWlCOATING A U 8 1o0°i METHANOL COMPATIBLEWrFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODI ROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [71 AUTOMATIC LINE LEAK DETECTOR [:j2 L E TIGHTNESS TESTING ❑ MONITORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ES M TE TE LAST USED(MOldAY1YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> DATE <br /> APPLICANTS NAME <br /> {PRINTED&53GN4.TUREI <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 N U-i PERMITA, ROVED.BYDATE PERMI P*IRATIOIWW� <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FI D. <br /> FORM s (9-90) { <br /> / 1��` ! � aRoa3ae-ru <br />