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�saU-•�3 <br /> STATE OFCALIFORNIA �- <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: , <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.X B. MANUFACTURED BY: r l <br /> C. DATE INSTALLED{MO/DAYYEAR) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. �I <br /> A. ❑ 1 MOTOR VEHICLE FUEL . a OIL B. C. 1aUNGULAR 3 DIESEL 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY 0 1 PRODUCT 1b PREMIUM 4 GASAHOL <br /> UNLEADED 5 JET FUEL 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN `Y WASTE [�] 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.T)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S-v: <br /> : <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BCX D <br /> A. TYPE OF [-] 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL a 4 SECONDARY CONTAINMENT (VAULTED TANK) E] 99 OTHER <br /> B TANK 1 BARE STEEL 2 STAINLESS STEEL El 3 FIBE=RGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL r7 5 CONCRETE 6 POLYVINYL CHLORIDE 0 7 ALUMINUM B 100% METHANOL COMPATIBLE WIFRP <br /> (PrimaryTarlk) 9 BRONZE 10 GALVANIZED STEEL F1 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR NR5 GLASS LINING ER 6 UNLINED F7 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% MENANOL? YES_ NO_ <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 0 95 UNKNOWN Q 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U ` GRAVITY A U 99 OTHER <br /> B, CONSTRUCTION A U 1 4SINGLE 'NALC-, A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 7 BAR�STEC,, p U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FEBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING <br /> A U B 100% METHANOL COMPATIBLE W;FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION E I AUTOMATIC LINE LEAK DETECTOR � LINE TIGHTNESS TESTING 3 INTERSTITWL 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> f " <br /> J 1 VISUAL CHECK 2 INVENTORY RECONCiLiAT10N 3 VAPOR MONITORYNG 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 6 TANK TESTING Q 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH YES C NO <br /> c SUBSTANCE REMAINING C, GALLONS ' INERT MATERIAL? ti <br /> I <br /> THIS FOPM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PAINTED 8 SIGNATURES <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICT)ON# FACILITY# TANK# <br /> STATE I.D.# HN <br /> PERhl17 NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION CATS <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR0}4B-R4 <br />