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L.J <br /> u� <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B da, <br /> • CSI IIpn N� �. <br /> COMPLETE A SEPARATE FORM FCR EACH TANK SYSTEM. <br /> MARK ONLY a 1 NEW PERMIT 0 3 RENEWAL PERMIT Ej 5 CHANGE OF INFORMATION 7 PERMANENTLY C OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED P RMIT - D 6 TEMPORARY TANK CLOSURE Q g 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.w V _ B. MANUFACTURED BY: G <br /> C. DATE INSTALLED(MO DAV/YEAR) D. TANK CAPACITY IN GALLONS: I I'✓0 0 <br /> II.TANKCONTENTS IF A•1 IS MARKED.COMPLETE ITEM C. <br /> This tc+-.k- Is ►��r�vv y <br /> 1 MOTOR VEHICLE FUEL 4 OIL 8. C. O 1iUN UNLEADED REGULAR ?� 3 DIESEL g AVIATION GAS <br /> A. 4 GASIWOI <br /> Q 2 PETROLEUM O 80 EMPTY1 PRODUCT O 1bPREMIUM <br /> UNLEADED Ej 5 JET FUEL 7 METHANOL <br /> Ej 3 CHEMICAL PRODUCT a 95 UNKNOWN O 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.•: J <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> A. TYPE OF <br /> SYSTEM O 2 SINGLE WAIL � 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> O 1 BARE STEEL El 2 STAINLESS STEEL 3 FIBERGLASS STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL s CONCRETE <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN Ej 99 OTHER <br /> El 1 RUBBER LINED 2 ALKYD LINING O 3 EPDXY LINING D 4 PHENOLIC LINING <br /> C.INTERIOR a 5 GLASS LINING W6 UNLINED 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 1009: METHANOL 7 YES NO <br /> D.CORROSION C] 1 POLYETHYLENE WRAP E] 2 COATING 3 VINYL WRAP P�r4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION Ej 91 NONE 0 95 UNKNOWN E] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) C OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFLINDERGROUND,BOTHIFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A@ 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A 0 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)AO 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 [j 2 UNE TIGHTNESS TESTING NRR 99 OTHER <br /> V.TANK LEAK DETECTION <br /> CI 1 VISUAL CHECK a 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> C� 6 TANK TESTING W7 INTERSTITIALMONITORING O 91 NONE O 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 A/11�1GALLONS I INERT MATERIAL? ,/) S 0 NO� <br /> THIS FORM HAS BEEN CO PLT NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDpGgE, IS TRUE AND CORRECT <br /> NTED&T'SN E nT <br /> ( j <br /> -.( PRINTED d SIGNA URE) <br /> P <br /> \ LOCAL AGENCY US -ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK#(' & <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE D r <br /> THIS FORM MUST BE ACCO ' IED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORM B (12-91) (, <br /> FILE THIS FORM W CAL AGENCY IMPLEMENTING THE UNDERGROUN E TANK REGULATIONS <br /> �3 I - 7 <br />