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QO <br /> STATEOFCAUFORMASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY i NEW PERMIT � 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE REM [-] 2 INTERIM PERMIT O 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 0 B TANK REMOVED O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -,S(- / I 57-6 0_ 4144 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK 1.D. I'D I B. MANUFACTURED BY: 2x'A <br /> C. DATE INSTALLED(MO/DAYNEAR) Y/ 199 D. TANK CAPACITY IN GALLONS: I'p OCU U <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1aUNL 3 DIESEL 6 AVIATIONGAS <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT 0 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> O 3 CHEMICALPRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF x 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 0 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL E:l 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> B. TANK F-1 1 BARE STEEL 0 2 STAINLESS STEEL 3 FIBERGLASS A4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL D 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UN104OWN O 99 OTHER <br /> O i RUBBER LINED 2 ALKYD LINING 0 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING E2<6 UNLINED 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO_ <br /> D.CORROSION F--j 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION IK91 NONE O95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL 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 <br /> A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A01 SINGLE WALL A U 2 DOUBLE WALL AIDS 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 04 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER_ <br /> D. LEAK DETECTION 01 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 <br /> MONRORING o W OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING X4 AUTOMATIC TANK GAUGING E:] 5 GROUNDWATER MONITORING <br /> O 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN W OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANCE REMAINING GALLONS I INERTMATERIAL7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NA �Zn*ja DATE <br /> IPRINTE9a6*W! e ,rW _ _ C <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE F UR NUMBERS BELOW J <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 /> FOR001/8R5 <br /> f - <br />