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Ai. <br /> e•• n <br /> 4 '+ <br /> 0 <br /> STATE OF CALIFORNIA ��• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> Cil r pq N+h, <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> 5 CHANGE OF INFORMATION ❑ 7 ANENTLY CLOSE N S <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5' <br /> MARK ONLY � ❑ q AMENDED PERMIT � 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> ONE ITEM Lf f�Jl 2 INTERIM PERMIT <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED; f `� <br /> I. TANK DESCRIPTION COMPLETE A EMS-- PE Y IF UNKNOWN B MANUFACTURED BY: w"� <br /> A. OWNER'S TANK I.D.# <br /> D. TANK CAPACITY IN GALLONS: 5() <br /> C. DATE INSTALLED(MOlDAYIY_ARI <br /> II.TANKCONTENTS IFA-I ISMARKED,COMPLETE EMC. 1a REGULAR 3 DIESEL 6 AVIATION GAS <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C^ ❑ UNLEADED 4 GASAHOL <br /> A � 7 METHANOL <br /> BO EMPTY 1 PRODUCT 1b PREMIUM <br /> 2 PETROLEUM ❑ ❑ ❑ UNLEADED 5 JET FUEL <br /> 95 UNKNOWN �y�WASTE ❑ 2 LEADED F bTHER (DESCRIBE IN ITEM D. BELOW, <br /> 3 CHEMICAL PRODUCT V� <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 5 i <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX 0 AND E <br /> 3 SINGLE WALL WITH EXTERIOR LINER [IA• TYPE OF 95 UNKNOWN <br /> ❑ 1 DOUBLE WALL <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLAS74C <br /> 7-1 B. TANK B 100°/ METHANOL COMPATIBLE WfFRP <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM <br /> (Primary Tank) F-� 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 UNLINED UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO <br /> ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP [_] 2 COATING — <br /> PROTECTION [� <br /> 5 CATHODIC PROTECTION 1 NONE 95 UNKNOWN 99 OTHER <br /> E,SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) _ <br /> ---------------- <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLEGRAVITY <br /> GRAVITY A U 99 OTHER <br /> A. SYSTEM TYPE A U 1 sucTlflN A U a PRESSURE_ A <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 I 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 W7 COATING A U B 100'0 METHANOL COMPATIBL€WIFRP <br /> PR©TECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER i <br /> 3 SN S TIAL 99 OTHER <br /> D, LEAK DETEOTION p 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK L J 2 INVENTORY RECONCILIATION � 3 VADOZE MONITORING � 4 AUTOMATIC TANK GAUGING E] 5 GROUND WATER MONITORING <br /> s TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE ❑ <br /> 95 UNKNOWN ❑ 99 OTHER <br /> VI,TAMC CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES No� <br /> 2.ESTIMATED QUANTITY Or0: INERT MATERIAL? <br /> 1.ESTIMATED DATE L�ST2D( DAY YRJ SUBSTANCE REMAINING GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY —7KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW -SANK# <br /> COUNTY# JURISDICTION# FACILITY# _ --- <br /> STATE l.D,# 1� ► l 'a Lq l I1 y <br /> PERMIT APPROVED BYIDATE P,F,Rml x; r ON DATE <br /> PERMITNUMBER {{�� �� 7 <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. ir4ll <br /> FILETHIS FORM WITHTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> F11111 11 <br /> FORM B (12-91} <br /> • 1 / V11L `'If <br />