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'yyo <br /> STATE OF CALIFORNIA ,..,•'_ <br /> STATE(NATER RESOURCES CONTROL BOARD <br /> �,ND STORAGE TANK PERMIT APPLICATION-FORM B <br /> �NO�R tbi1Pl ETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> 5 CHANGE OF INFORMATION ❑ 7 pEFwANENTLY CLOSED ON SITE <br /> ❑ 3 --NEWAL PERMIT _ RE ❑ B TAW it <br /> C A AM=_HOED PERM'- I S TEMPORARY TANK CLOSU <br /> �o 0 <br /> (STALLED: <br /> J 1 <br /> OEALL ITEMS- SPECIFY IF UNKNOWN S, MANUFACTURED BY: <br /> M I D.TANK CAPACITY IN GALLONS: DV� <br /> OQ <br /> OeP �Q fA-rIS MARKED.COM�LEOIL ITEM C. B p ❑ 1eUNLEADED '� 3 DIESEL ❑ 7^WATIOMETA) GAS <br /> FUEL ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL <br /> \ O" BO EMPTY ' UNLEADED❑ UNLEADED ❑ 5 JET FUEL <br /> P' Y ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(ESCRff N REM D. BELOW) <br /> LAL PRODUCT ❑ 95 UNKNOWN ❑ <br /> C.A.S.# <br /> AARKED.ENTER NAME OF SUBSTANCE STORED <br /> ,46TRUCTION MARK ONE ITEM ONLY IN BOXES A,13,ANDD.AMALLTHATAPPLIES INBOXDAND 95 UNKNOWN <br /> ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WRB EXTERIOR LINER <br /> ❑ 99 OTHER <br /> a TYPEEM 4 SECONDARY CONTAWMENT (VAULTED TANK) <br /> SYSTEM �2 SINGE WALL <br /> 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTID <br /> 1 BARE STEEL D1 <br /> B. TANK ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM <br /> ❑ 9 100% METHANOL COMPATIBLE%FRP <br /> MATERIAL ❑ 5 CONCRETE ❑ 99 OTHER <br /> E:] 9 BRONZE ❑ 10 GALVANIZED STEEL <br /> (PrimaryTank) ❑ 95 UNKNOWN <br /> ❑ 2 ALKYD LINING a,EEOXV LINING ❑ 4 PHENOLIC LINING <br /> ❑ 1 RUBBER LINED 2995 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR ❑ B UNLINED <br /> ❑ 5 GLASS LINING <br /> LINING <br /> NO— <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ <br /> ❑ 2 COATING VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION F-11 POLYETHYLENE WRAP 95 9t <br /> UNKNOWN ❑ 99 OTHER <br /> PROTECTION E] 5 CATHODIC PROTECTION ❑ 91 NONE ��'LLLJJJ <br /> E.SPILL AND OVERFILL <br /> 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 OTHER <br /> A. SYSTEM TYPE 1 SUCTION p U 2 PRESSURE A U 3 GRAVITY A U _ <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 95 NKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U / 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 a CONCRETE A U 7 STEEL W1 COATING A U 8 100% METHANOL COMPATIE_E v: nP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION9 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION <br /> ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 UAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING L) 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION 3.WASTANKFILLEDwRH <br /> 2.ESTIMATED QUANTITY OF ❑ <br /> 1.ESTIMATED DATE LAST USED(MO/DAVIVR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ !q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF AIY XNOWLEDGF- 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 ).D.# = LZCpf,�A <br /> PERMITNUMBEfl ERMIT APPROVED eV/DATE PERMIT EXPIRATION DATE fIcil raft7 <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.( <br /> ! � tAl! FOR907 i5 <br />