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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a� a <br /> COMPLETE A SEPARATE FORM FO!!5HIM SYSTEM <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OFF 1 gA4kPI 7 PERMANENTLY CLOSED ONJ=E <br /> ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT PORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q��\eNjmnI / <br /> I. TANK DESCRIPTION COMPL TE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. X 1 MOTOR VEHICLE FUEL 4 OIL B, C 1a REGULAR 3 DIESEL 6 AVIATION GAS <br /> UNLEADED a 4 GASAHOL <br /> 2 PETROLEUM 80 EMPTY 1 PRODUCT a 1bUN UNLEADED 5 JET FUEL D 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE � 2 LEADED E] 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 OF1 DOUBLE WALL F--j 3 SINGLE WALL WITH EXTERIOR LINER a 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) F-� 99 OTHER <br /> B. TANK 0 1 BARE STEEL 2 STAINLESS STEEL FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE F--] 6 POLYVINYL CHLORIDE n7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) ❑ 9 BRONZE El 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-] 2 ALKYD LINING F73 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING 5 GLASS LINING F-16 UNLINED F--] 95 UNKNOWN a 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION 0 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION D 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL 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 U 1 SUC ESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A -1SINGLE WALL FL 2 .DOUG A A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BA A LESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A j 4 IBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 1009/ 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 AUTOMATIC LINE LEAK DETECTOR D 2 LINE TIGHTNESS TESTING 3IAL gg OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 1 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING [::] 5 GROUND WATER MONITORING <br /> E <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING O 91 NONE 95 UNKNOWN E] 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 0 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 M <br /> (PRINTED&SIGNATURE) ` j V-9 <br /> t <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR N BERS BELOW I�J <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMITNUMBER PERMIT APPROVED BY/DATE P RM IT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. + <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (12-91) ORO R6 <br /> 6 0 <br /> L <br />