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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W u <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION a PERMANENTLY CLOSED ONSITE <br /> ONE ITEM F--] 2 INTERIM PERMIT a 4 AMENDED PERMIT E::] 6 TEMPORARY TANK CLOSURE TANK REMOVED <br /> AC� <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4;::� h S <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) c, 4) D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 5;?'-'l-MOTOR VEHICLE FUEL 4 OIL g, C �y REGULAR 3 DIESEL 6 AVIATION GAS <br /> A � 2 PETROLEUM � 80 EMPTY 1 PRODUCT �1 1b PREMIUM UNLEADED 4 GASAHOL <br /> 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT a 95 UNKNOWN Ej 2 WASTE O 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 DOUBLE WALL F-� 3 SINGLE WALL WITH EXTERIOR LINER F-] 95 UNKNOWN <br /> SYSTEM E�J 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) F--] 99 OTHER <br /> B. TANK BARE STEEL F-] 2 STAINLESS STEEL 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F-] 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) 9 BRONZE E:l 10 GALVANIZED STEEL E] 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING <br /> C.INTERIOR F-] 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER <br /> _ <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION E 1 POLYETHYLENE WRAP a 2 COATING D 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-� 5 CATHODIC PROTECTION [-] 91 NONE 5 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF A13OVE 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 A Cl 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 ST L W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 31 S A g <br /> MONITORING g OTHER <br /> V.TANK LEAK DETECTION <br /> 1 y1SUAL CHECK F-] 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING [::] 5 GROUND WATER MONITORING <br /> 66 TANK TESTING [::] 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN F--] 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATE ATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF QQ 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING J� GALLONS INERT MATERIAL? YES NO <br /> THIS FORM HAS qgEACOMPLETED UNDER PENALTY OF PERJUR AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAM DATE <br /> (PRINTED 8 SIGNATU <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BEL <br /> STATE I.D.# <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> ID . q4w/PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA EEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK gUL NS <br /> FORM B (12-91) FOR00346•R6 <br /> • B��a'WF4 <br />