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0 0 <br /> STATE OF CAUFORMA .` c <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD -„� P <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B Ye, �,,, o <br /> C�I,�OYY,� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED Q� <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> O/S <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 8 MANUFACTURED BY: vyJ <br /> A. OWNER'S TANK I,D.M <br /> d Z D. TANK CAPACITY IN GALLONS: <br /> C. DATE INSTALLED(MOIDAV/YEAR) D <br /> VD <br /> ONTENTS IFA-1 IS MARKED.GOMPLETEITEM C. aREGU1 3 DIESEL ❑ 6 AVIATIONGAS <br /> MOgMARKFID <br /> ;EN7ER <br /> L ❑ 4 OIL B. C. -❑ UNLEADED 4 GASAHOL <br /> ❑ W EMPTY 1 PRODUCT ❑ ��PREMIUMUNLEAD D 5 JET FUEL ❑ 7 METHANOL <br /> PE <br /> CH ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> S NONAME OF SUBSTANCE STORED <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN 00X0 <br /> 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> SYSTEM 2 SINGLE WALL ❑ <br /> 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 0 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL ❑ <br /> (Primary Tank) ❑ 9 BRONZE ❑ t0 GALVANIZED STEEL 0 95 UNKNOWN ❑ 99 OTHER <br /> 1 RUBBER LINED ❑ 2 ALKYD LIN NG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 1009:METHANOL? VES_ NO_ <br /> AP 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WR ❑ <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 5 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 /> CONCRETE A U 7 STEEL WI COATING A U S 100% METHANOL COMPATIBLE W/FRP <br /> CORROSION A U 5 ALUMINUM A U 6 <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR INE TIGHTNESS TESTING <br /> ❑ MONITORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> TANK TESTING ❑ 7 INTERSTITIAL MONITORING ED <br /> NONE 96 UNKNOWN 98 OTHER <br /> VI.TANK CLOSURE INFORMATION IMATED TY OF 3.WAS TANK FILLED WITH <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2-ESUSTANCE REMAINING INING GALLONS IN <br /> MATERIAL? YES ❑ NO[:] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED 6 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.DA � rT� O O <br /> PERMIT NUMBER PERMIT AP PROVED BY/DATE PERMIT EXPIRATION DATE �'�yZ <br /> FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR6ax6-a4 <br />