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c4`yn'�9 Cr. <br /> STATE Of CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT <br /> G APPLICATION - FORM B <br /> f3% <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY L� 1 NEW PERMIT 3 RENEWAL PERMIT F--1 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 17 2 INTERIM PERMIT Q 4 AMENDED PERMIT a 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: w N 14 N a W k, <br /> C. DATE INSTALLED(MOICAY/YEAR} I!��D r5 D. TANK CAPACITY IN GALLONS: jJ S <br /> 11.TANK CONTENTS IFA-IISMARKED.COMPLETEITEMC- <br /> is REGULAR <br /> A � 1 MOTOR VEHICLE FUEL � 4 OIL B. C. UNLEADED 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY d 3 DIESEL ID <br /> PRODUCT tbPREMIUM 4 GASAHOL 7 METHANOL <br /> _ UNLEADED O 5 JET FUEL 1 <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S-x: <br /> 111, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF [7 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM E 2 SINGLE WALL a 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> a <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC <br /> _ <br /> MATERIAL 5 CONCRETE 0 6 POLYVINYL CHLORIDE 7 ALUMINUM B 100^. METHANOL COMPATBLEWIFRP <br /> (Primary Tank) 0 9BRONZE Li 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> Y 1 RUBBER LINED F-1 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING 0 5 GLASS LINING = & UNLINED 95 UNKNOWN � 99 OTHER i <br /> r•-, IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.CORROSION Cl 1 POLYETHYLENE WRAP 0 2 COATING 0 3 VINYL WRAP a 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION = 91 NONE 95 UNKNOWN Q 99 OTHER <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 U 2 PRESSURE A U 3 GRAVITY AID 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A(D 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 PCLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE I <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U B 100% METHANOL COMPATIBLE VFFR? 1 <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A(g)95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR D 2 LINE TIGHTNESS TEI <br /> STING 0 3 INTERSTITIAL <br /> MONTORING L__] gg OTHER <br /> i <br /> V.T NK LEAK DETECTION <br /> eeC` <br /> J ! VISUAL CHECK CI 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING4 AUTOMATIC TANK GAUGING 5 GROUND WATER f.10N€TORI.G <br /> C� 6 TANK TESTING 7 INTERSTITIAL MONITORING F-1 91 NONE 95 UNKNOWN 99 OTHER i <br /> VI,TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOIDAYlYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO CI <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE, 1S TRUE AND CORRECT <br /> APPLICANT'S NAME DATE <br /> (PRINTEO a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER 1S COMPOSED OF THE FOUR NUMBERS BELOW l 1 1 <br /> COUNTY# JURISDICTION# FACILITY# TANK P <br /> STATS I.D.# m n <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <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 /> FOROZ43-FA <br />