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Fyeo�Rre CG <br /> STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> - FORM B <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ED ON I <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE �Q <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A- OWNER'S TANK I.O.N S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAY/YEAR) vt?A, D. TANK CAPACITY IN GALLONS: <br /> II.TANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL IL B. C. ❑ laREGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS <br /> A. 4 GASAHOL <br /> 2 PETROLEUM gF7 <br /> ioUNKNOWN <br /> EMPTY ❑ 1 P ❑ 16UNLEAIUM QED ❑ 5 JET FUEL 7 METHANOL <br /> ❑ 3 CHEMICAL PRODUCT 2 WASTE ❑ 2 LEADED ❑ 99 OTHER ;DESCRIBE IN ITEM D. BELOW) <br /> 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 0 C.A.S.8 <br /> III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D <br /> ❑ 1 DOUG L ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A. TYPE OF 99 OTHER <br /> SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC <br /> B. TANK5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEWIFRP <br /> MA7ER4AL L� <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �9 KNOWN ❑ 99 OTHER <br /> 7-11 RUBBER LINED ❑ 2 ALKYD LINING 1❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �NKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION F-:] 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION L:-] 5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN E:] 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUND OA U IFUNDERGROUN , O IFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 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 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A UNKNOWN A U 99 OTHER <br /> 3 iNTERSTIT6AL gg OTHER <br /> D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING ❑ MONITORING <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> ESTIMATED DATE LAST USEQ(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES I '' NO r <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? u <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> [PRINTED S SIGNATUREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK It <br /> STATE I.D.# F= 5s' 1lmolOLllv <br /> PLRMIT NUMBER PERMIT APPROVED BY10ATE PERMIT EXPIRATION DATE I <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> 8 v\ <br />