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rzz,ua c,�c <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD w�, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ,, o= <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 SED ON SIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - �- <br /> yn <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: - <br /> G. DATE INSTALLED(MOIDAYNEAR} D. TANK CAPACITY IN GALLONS: / <br /> II.TANK CO TENTS IFA-115MARKEO,COMPLETEITEMC. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1a REGULAR 3 DIESEL ❑ 6 AVIATION GAS <br /> A UNLEADEDPREMIUM ❑ 4 GASAHOL <br /> ❑ 2 PETROLEUM 80 EMPTY 1 PRODUCT ❑ 1�UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN a 2 WASTE 2 LEADED a 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.&a <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> F-1 [D1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> A. TYPE OF <br /> SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK �--y 6 POLYVINYL CHLORIDE 7 ALUMINUM a 100% METHANOL COMPATIBLEW6FAP <br /> MATERIAL I—I 5 CONCRETE ❑ ❑ <br /> (PrimaryTank) 9 BRONZE ❑ GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 LKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 U INED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100 METHANOL? YES_ Nfl— <br /> Q.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COAT G ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 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 I UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE�Ul <br /> A U 2 PRESSUR A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTIOWALL A U 2 DOUBLE LL 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 TEEL 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 B 100"l METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PR TECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LIN IGHTNESS TESTING ❑ 3 IMONITORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE M NITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED ANDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 8 SIGNATURE) <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.# <br /> PER N B'ER ERMIT APPROVED BYlDATE PERMIT EXPIRATION DATE <br /> 1 <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> • � � ��Fy„� ��� F0900346•145 <br />