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STATS OF CALIFORNIA !l <br /> l.� STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "e� ; "° ; <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY EF}-flN TE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED7;7 <br /> J <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / f jC <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.if d B. MANUFACTURED BY: LAµ <br /> G. DATE INSTALLED(MOIDAYN EAR) { `, D. TANK CAPACITY IN GALLONS: (J1 <br /> II.TANKC,ONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> F <br /> MOTOR VEHICLE FUEL 4 OIL B. i f C 1a UNLEADEfl 3 DIESEL ❑ 6 AVIATION GAS <br /> 4 GASAHOL {� 7 METHANOL <br /> PETROLEUM 80 EMPTY PRODUCT D 1bUNLEAIUM <br /> DED 5 JET FUEL L 1 <br /> CHEMICAL PRODUCT 95 UNKNOWN F 2 WASTE 2 LEADED 99 OTHER {DESCRIBE IN ITEM D. RELOWI <br /> IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND RLL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF �0 11 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM Imo/ 2 SINGLE WALL F—] 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL L] 3 FIBERGLASS 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC <br /> B. TANK6 POLYVINYL CHLORIDE 7 ALUMINUM L] 6 100'/ METHANOL COMPATIBLE WIFRP <br /> MATERIAL Cf 5 CONCRETE <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER _ <br /> 1 RUBBER LINED 2 ALKYD LINING Q 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED [?r'95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100✓ METHANOL? YES_ NO <br /> D.CORROSION 0 1 POLYETHYLENE WRAP ❑ 2 COATING L-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION a 5 CATHODIC PROTECTION 91 NONE ,r'4 5 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL i SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH T APPLICABLE <br /> A. SYSTEM TYPE A[o1)-1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 10l 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 WlCOATING A U B 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AS&D UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ a MONff0ERS1RING � 49 OTHER <br /> V.TANK LEAK DETECTION <br /> 1.VISUAL CHECK [:Er-2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING E) 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST US€D{MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> Yes L--_] NO Cl <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> {PRINTED&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.# 3 '3 �� <br /> PERMIT NUMBER PERMIT APPROVED BYJDATE PERMIT EXPIRATI)yIN.DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (12-91) 0 0 FOR0034B.R6 <br />