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Peb.UR <br /> STATE OF CALIFORNIA r <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> d <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY F-� 1 NEW PERMIT F--j 3 RENEWAL PERMIT - 5 CHANGE OF INFORMATIONPERMANENTLY CLOSED ON SITE <br /> ONE ITEM 7 2 INTERIM PERMIT F-� 4 AMENDED PERMIT 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 1.D.* B. MANUFACTURED BY: <br /> Ve- <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: pttv ' <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 TOR VEHICLE FUEL 4 OIL g, C to REGULAR a 3 DIESEL 6 AVIATION GAS <br /> A UNLEADED F-] 4 GASAHOL <br /> 2 PETROLEUM a 80 EMPTY PRODUCT 1bUNLEADMP__A-<TUEL � 7 METHANOL <br /> 3 CHEMICALPRODUCT ED95 UNKNOWN [:] 2 WASTE Ej 2 LEADED 99ER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 1 - C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF OUBLE WALL F-1 3 SINGLE WALL WITH EXTERIOR LINER a 95 UNKNOWN <br /> SYSTEM KI 2 SINGLE WALL F;4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK F-� 1 BARE STEEL Q 2 STAINLESS STEEL F--j 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-� 5 CONCRETE O 6 POLYVINYL CHLORIDE F-� 7 UMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) E:] 9 BRONZE Q 10 GALVANIZED STEEL 95 UNKNOWN a 99 OTHER <br /> 1 RUBBER LINED Q 2 ALKYD LINING ❑ OXY LINING E] 4 PHENOLIC LINING <br /> C.INTERIOR � 5 GLASS LINING 6 UNLINED 95 UNKNOWN E] 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION F-1 1 POLYETHYLENE WRAP F--j 2 COATING ® 3 INYL WRAP � 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV.PIPING INFORMATI N CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U / 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 6>5 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 STQELWICOATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR ® 2 LINE TIGHTNESS TESTING 0 3 INTERSTITIAL 0 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> E61 F--]VISUAL CHECK El 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING� 4 AUTOMATIC TANK GAUGING 5 GROUNDWATER MONITORING <br /> TANK TESTING 0 7 INTERSTITIALMONITORING 91 NONE 95 UNKNOWN 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 <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <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 S SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# I <br /> STATE IBMFm- 106-110 l f ® / <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 /> FOR0034B•R4 <br />