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StiURCC3 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDAt <br /> , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> ra, . <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, <br /> MARK ONLY ❑ 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ej 7 PERMANENTLY LOSED ON S1 <br /> ONE ITEM F72 INTERIM PERMIT F74 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOV D o/ <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -3 TC /I <br /> I. TANK DESCRIPTION COMPLETE ALL ITLMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# I B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYIYEAR) ! D. TANK CAPACITY IN GALLONS: w <br /> 11.TANK ,RWEN7 IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B, C a REGULAR 3 DIESEL ❑ 6 AVIATION GAS <br /> UNLEADED 4 GASAHOL <br /> A 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ❑ 1hPREMiUM ❑ 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE LEADED OTHERUNLEADED 99 JL <br /> 2 (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x <br /> 111, 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 ❑ 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 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM S 100°/ METHANOL COMPATIBLE WIFRP <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL a 95 UNKNOWN O 99 OTHER <br /> F7 1 RUBBER LINED F7 2 ALKYD LINING 7] 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 10056 METHANOL? YES NO <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE KNOWN 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 1 SUCTION AV PRESSURE A U 3 GRAVYTY A U 99 OTHER <br /> B. CONSTRUCTION AV 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 6 CONCRETE A U 7 STEEL WICOATING A U 6 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A V 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A095 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION <br /> F 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 9 MONITORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK INVENTORY RLCONC6LIATION 3 VADOZE MONITORING Q 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED W ITH 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 /> APPLICANTS NAME PATE <br /> (PiINTW 3 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> CO # JURISDICTION <br /> �# FACILITY# TANK# ��"1JeNr <br /> STATE I.D.# 6 r <br /> PLRMITNUMBLH - PERMIT AP PROVED 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 /> /�� F,dR6S+4B- <br />