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STATE OF CALIFORNIA J'c5 "JC°+ <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c""°""�� <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 557 U \� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS.. SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# v, B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) v/- D. TANK CAPACITY IN GALLONS: O d V <br /> II.TANKCO ENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> i MOTOR VEHICLE FUEL O 4 OIL B. C. 1aUNLEADED LAR 3 DIESEL O 6 AVIATION GAS <br /> A 4 GASAHOL <br /> O 2 PETROLEUM 0 80 EMPTY 1 PRODUCT �� 1byPREMIUM <br /> DED 5 JET FUEL El T METHANOL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE �V5 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. 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,8,AND C,AND ALL THAT APPLIES INBOX DAND E JCS' '+ /J �. , Q <br /> A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 2r.5 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER <br /> B. TANK O 1 BARE STEEL 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE T ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (RlmuyTenk) O g BRONZE O 10 GALVANIZED STEELUNKNOWN O 99 OTHER <br /> 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING a 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED <br /> LINING 95 UNKNOWN O 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 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 IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 42DIS UNKNOWN A U 90 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 T STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION fu-;36 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION E 1 AUTOMATIC LINE LEAK DETECTOR2 LINE TIGHTNESS TESTING 31 <br /> 0 MONITORING �99 OTHER <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING E 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATERMONITORING <br /> O 6 TANK TESTING O ? INTERSTITIAL MONITORING O 91 NONE 15SUNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE1AST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> `G SUBSTANCE REMAININGy.K. GALLON3 INERT MATERIAL? YES O NO O <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 8 SIGNATURE) T��1 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW '/ <br /> COUNTY# JURISDICTION# I TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE 7-T- <br /> FORM 0 (7 91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILLED, <br />