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STATE OF CALIFORNIA 1• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> CO PLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ���.u,�;• <br /> MARK ONLY 1 NEW PERMIT t 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED ®� <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# f B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: / <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> REGULAR <br /> F--] 1 MOTOR VEHICLE FUEL 4 OIL B. C. taUNLEADED a 3 DIESEL 6 AVIAT'ON GAS <br /> AF-] 2 PETROLEUM 0 80 EMPTY a1 PRODUCT � 1b PREMIUM a GASAHOL 0 7 METHANOL <br /> UNLEADED 0 5 JETFUEL <br /> 3 CHEMICAL PRODUCT a 95 UNKNOWN a 2 WASTE [:j 2 LEADED a 99 OTHER (DESCRIBE IN ITEM 0. 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 F7 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER [:] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL F7 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> a <br /> B. TANK 1 BARE STEEL a 2 STAINLESS STEEL a 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED°LASTIC <br /> MATERIAL 0 5 CONCRETE F-] 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) a 9 BRONZE 0 10 GALVANIZED STEEL o 95 UNKNOWN O 99 OTHER <br /> 0 1 RUBBER LINED F-1 2 ALKYD LINING 3 EPDXY LINING a 4 PHENOLIC LINING <br /> C.INTERIOR 0 5 GLASS LINING O 6 UNLINED F-1 95 UNKNOWN a 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION 0 1 POLYETHYLENE WRAP 2 COATING 0 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F--j 5 CATHODIC PROTECTION O 91 NONE 0 95 UNKNOWN F-1 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTHIFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 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 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 W/COATING A U 8 100% METHANOL COMPATIBLEW;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 0 [:]AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING 3 S I NAG! D 99 OTHER <br /> MONRO <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK a 2 INVENTORY RECONCILIATION F-� 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING [:] 5 GROUND WATER MON''ORING <br /> 6 TANK TESTING a 7 INTERSTITIAL MONITORING F'I 91 NONE 95 UNKNOWN 0 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES D NO 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 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.D.# m 2 <br /> PERMITNUMBER PERMIT APPROVED BY/DATE P RM IT EXPIRATION 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) (J <br /> 7/1 91 <br /> (& b FCROO:ii46-R6 <br />