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I STATE OF CALIFORNIA rP . <br /> ma STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> I - <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: rpIc' <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# 1 r x t i B. MANUFACTURED BY: 1 t <br /> C. DATE INSTALLED(MO/DAYEAR) �W D. TANK CAPACITY IN GALLONS: <br /> /Y <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. V <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. C• 1aREGULAR UNLEADED 3 DIESEL O 6 AVIATION GAS <br /> r7 2 PETROLEUM 80 EMPTY 1 PRODUCT 1b PREMIUM D 4 GASAHOL 7 METHANOL <br /> UNLEADED a 5 JET FUEL <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.#: <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 F-1 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ED 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL F—] 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM El 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) D 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br />,'s 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING 5 GLASS LINING 6 UNLINED � n95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE UNKNOWN 99 OTHER <br />�A E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) "NW40k1bARFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A( 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A69 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH X95 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 p U 9 GALVANIZED STEEL p U 10 CATHODIC PROTECTION A95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL <br /> MONITORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> _ <br /> F 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> �,- <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING F791 NONE E 95 UNKNOWN 99 OTHER <br /> ' VI.TANK CLOSURE INFORMATION <br /> FsTIMATED ATE ST USEDIMO/DAY/YR) 2.ESTIMATED QUANTITY OF /y 3.WAS TANK FILLED WITH YES NO <br /> .r SUBSTANCE REMAINING Z„ GALLONS INERT MATERIAL? <br /> :z <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOT BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME } �w {;' y,t ... DATE <br /> _ (PRINTED B SIGNATURE)•�f,�,,, 1C � ' _t !l(,I + �!"' V� )• <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> z COUNTY# JURISDICTION# FACILITY# TANK# <br /> ` STATE I.D.# m _ <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE - <br /> THIS FORM MUST BE ACCOMPANIED -Y A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (12-91) - -+w FOR0034B-R6 <br />