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'`SOV R0�9 O <br /> STATE OF CALIFORNIA r oti <br /> STATE WATER RESOURCES CONTROL BOARD s� V• g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> 1 j <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY F--1 1 NEW PERMIT F-] 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED TE <br /> ONE ITEM O2 INTERIM PERMIT ED AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE ' 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: `�� - 14 11 7 <br /> !sem <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A OWNER'S TANK 1.D.# 141 1 _ ' B. MANUFACTURED BY: n kncy ort <br /> C. DATE INSTALLED(MO/DAYNEAR) , 7 2 D. TANK CAPACITY IN GALLONS: 101000 <br /> II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> A. M 1 MOTOR VEHICLE FUEL a 4 OIL B. C. 1a REGULAR UNLEADED D 3 DIESEL 6 AVIATIONGAS <br /> F--] 2 PETROLEUM O BO EMPTY Pin 1 PRODUCT ib PREMIUM UNLEADED Q 4 GASAHOL 0 7 METHANOL <br /> Q 1c MIDGRADE UNLEADED D 5 JET FUEL 0 8 M85 <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE E] 2 LEADED El 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE 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 E <br /> A. TYPE OF F-j 1 DOUBLE WALL f--] 3 SINGLE WALL WITH EXTERIOR LINER a 5 INTERNAL BLADDER SYSTEM [:] 95 UNKNOWN <br /> SYSTEM w 2 SINGLE WALL El 4 SINGLE WALL IN A VAULT 99 OTHER <br /> B. TANK RX 1 BARE STEEL a 2 STAINLESS STEEL F-� 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL r--1 5 CONCRETE F--] 6 POLYVINYL CHLORIDE F] 7 ALUMINUM F-1 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) [:] 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN [::] 99 OTHER <br /> C.INTERIOR O 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING a 4 PHENOLIC LINING <br /> LINING OR F-� 5 GLASS LINING O 6 UNLINED 95 UNKNOWN 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.EXTERIOR El 1 POLYETHYLENE WRAP a 2 COATING El 3 VINYL WRAP El 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> PROTECTION El 5 CATHODIC PROTECTION W 91 NONE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION Ao 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND AQ 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 W/COATING A U 8 100% 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 1 MECHANICAL LNE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE O 5 AUTOMATIC PUMP Q 99 OTHER <br /> DETECTOR TESTING MONITORING LTAK DETECTOR SHUTDOWN <br /> V.TANK LEAK DETECTION <br /> Q 1 VISUAL CHECK 2 MANUAL RECONCILIATION TANK <br /> I TIIONORY Q 3 VADOZE MONITORING 4 AUTOMATGAUGING NG IC TANK O 5 GROUNDWAMONITORING <br /> a 6 ANNUAL TESTING <br /> 7 CONTINUOUS <br /> INTERSTITIAL a 8 SIR 0 9 TANEK GA TESTING a 10 TEOSTINGY TANK 0 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E�] NO 0 <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 /> TANK OWNER'S NAME Z-olle- 'a C>fon1v1 �r DATE <br /> (PRINTED 6 SIGNATURE) F-l{.L � .rA I r (wyler 4/1lo -1g <br /> LOCAL AGENCY USE ONLY THE AQ <br /> I.D.NU E IS C OSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# a2l 14 <br /> STATE I.D.4 0 4 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIl '1N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Fr' 'MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT Pj *ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEE ;GROUND STORAGE TANK REGULATIONS <br /> FORM B (6-95) <br />