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yUUnce.9 <br /> STATE OF CALIFORNIAP�� `0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B n s <br /> c <br /> COMPLETE A SEPARATE FORM FOR EA TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 25�5 CHANGE OF INFORMATION E:7 7 PERMANENTLY ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVE <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D. B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIOAYNEAR) 0. TANK CAPACITY IN GALLONS: U CrrV <br /> 11.TANK CONTENTS iFA-1 ISMARKED,COMPL ITEM C. <br /> A 1a <br /> M <br /> I OTOR VEHICLE FUEL OIL B, n 3 DIESEL <br /> C. UNLEADED 8 AVIATION GAS <br /> Q 2 PETROLEUM BO EMPTY I PRODUCT PREMIUM �J 4 GASAHOL 7 METHANOL <br /> UNLEADED 5 4T FUEL <br /> B CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOM <br /> D. IF{A.1)ES NOT MARKED, ENTER NAME OF SUBSTANCE STORED CAS N: <br /> 11 1. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL 712 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE B POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 1W METHANOL COMPATIBLEW/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING F7 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING 5 GLASS LINING �NLfNEO E:� 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING E] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHOOiC PROTECTION Q 91 NONE5 UNKNOWN ❑ 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION 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 U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 8 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 UNKNOWN <br /> A U 99 OTHER <br /> D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR2 UNE TIGHTNESS TESTING iN <br /> MONrrCRING [] 99 OTHER <br /> V.TANK LEAK DETECTION <br /> JAL CHECK 2 INVENTORY RECONCILIATION E:] 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING a 5 GROUND WATCH MONITORING <br /> K TESTING 71 7 INTERSTITIAL MONITORING 91 NONE <br /> El 95 UNKNOWN F 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOJOAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <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 d SIGNATURE) <br /> W Z3 6 <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.# —' , o it <br /> PEAMITNUMBER I PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE 9 <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 /> FOR0094 RS <br />