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PP'6�P,Lg CO <br /> nP 4 <br /> STATE OF CALIFT7RMA g <br /> STATE WATER RESOURCES CONTROL BOARD w�� N�g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION, FORM B `aP , <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. P <br /> 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> 1 NEW PERMIT 6 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED <br /> MARK ONLY O <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMSSPECIFYIF UNKNOWN B. MANUFACTURED BY: U X . <br /> A. OWNERS TANK I.D.# D. TANK CDD <br /> APACITY IN GALLONS: <br /> C. DATE INSTALLED(MOIDAYA'EAR) <br /> II.TANKCONTENTS IFA-1 ISMARKED.COMPLETEITEM C. aREGULAR 3 DIESEL 6 AVIATIONGAS <br /> ❑ 4 OIL B. C. ❑ UNLEADED g 4 GASAHOL ❑ 7 METHANOL <br /> A ❑ 1 MOTOR VEHICLE FUEL ❑ 1 PRODUCT ❑ lbPREMIU <br /> UNLEADED <br /> ❑ 5 JETFUEL <br /> ❑ 2 PETROLEUM ❑ 2 WASTE 2 LEADED W OTHER (DESCRIBE IN ITEM D. BELOW) <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES AB,AND C.AND ALL THAT APPLE.Ekr95 UNKNOWN <br /> A. TYPE Of <br /> ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> ❑ 99 OTHER <br /> 4 SECONDARY CONTAINMENT (VAULTED TANK) <br /> SYSTEM ❑ 2 SINGLE WALL <br /> ❑ BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 1 <br /> B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE n ?/ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP <br /> MATERIAL ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> (PrimaryTank) ❑ 9 BRONZE <br /> O 2 ALKYD LINING ❑ 3 OXY LINING ❑ 4 PHENOLIC LINING <br /> 1 RUBBER LINED zi 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR6 UNLINED <br /> O 5 GLASS LINING <br /> LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHA�L' qs <br /> YES NO— <br /> 0.CORROSION ❑ 1 POLYETHYLENE WRAP <br /> ❑ 2 COATINGL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE <br /> NOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTHIFFAPPLICABLE GRAVITY p U 99 OTHER <br /> 1 SUCTION A U 2 PRESSURE A U <br /> A. SYSTEM TYPE UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION <br /> A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A� <br /> A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> C. MATERIAL AND 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 9 1001. METHANOL COMPATIBLE W/FRP <br /> CORROSION A U UNKNOWN p U 99 OTHER <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 3 IMMONST RO AL ❑99 OTHER P <br /> NG <br /> D. LEAK DETECTION ❑ 1 AUTO MATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING <br /> L—jtTANK LEAK DETECTION <br /> VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTO TIC TANK GAUGING❑ 5 GROUND WATER MONyITORING <br /> TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ <br /> 81 NONE 95 UNKNOWN ❑ 98 OTHER �m <br /> VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES ❑ NO[-] <br /> 2.ESTIMATED QUANTITY OF GALLONS INERT MATERIAL? <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) SUBSTANCE REMAINING <br /> OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY <br /> APPLICANTS NAME <br /> (PRINTED A SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# <br /> COUNTY# JURISDICTION# <br /> STATE I.D.# <br /> PERMIT EXPIRATION DATE <br /> PERMIT NUMBER ERMIT APPROVED BYIDATE <br /> FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FGR903413-114 <br />