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0 t60UR <br /> STATE OF CALIFORNA �P r "' co <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> �. <br /> COMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM. <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> J <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o(O- (M <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# sy B. MANUFACTURED BY: , CPr� ( (� <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: �'�� Q�/vim <br /> ILTANKCONTENTS IFA-1 IS MARKED.COMELETEITEMC. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C. Q la <br /> REGULAR <br /> 3 DIESEL 6 AVIATION GAS <br /> A. ❑ 4 GASAHOL <br /> 2 PETROLEUM O 80 EMPTY a 1 PRODUCT a 1bIDED 5 JET FUEL 0 7 METHANOL <br /> UNLEADED <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN V2 WASTE a 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 CONSTR CTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF FV <br /> 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM F-1 2 SINGLE WALL F--1 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL 0 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 0 9 BRONZE 1:1 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING 0 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING a 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION F-] 1 POLYETHYLENE WRAP ❑ 2 COATING 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION a 5 CATHODIC PROTECTION a 91 NONE 0 95 UNKNOWN 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 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 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 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING Q 3 INTERSTITIAL <br /> NTERSMONrrI GL 099 OTHER <br /> V.TANK LEAK DETECTION <br /> E] 1 VISUAL CHECK D 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING[::] 4 AUTOMATIC TANK GAUGING [::] 5 GROUND WATER MONITORING <br /> 6 TANK TESTING (jr[yJ(7 INTERSTITIAL MONITORING Ll 91 NONE E:l 95 UNKNOWN E:l 99 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 D NO <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 /> APPLICANTS NAME DATE <br /> (PRINTED&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.# ® j Ile 117 1 1 1 SY01APOI <br /> PERMITNUMBER PERMIT APPROVED BY/DATE / 6 <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 /> //F/O1R0034&jR4 <br /> / <br /> • �Ji�j,'// • / <br />