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0 0 ,0-- n <br /> STATE OF CALIFORNIA ^r ' <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT "I q5: CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO TE <br /> ONE ITEM F72 INTERIM PERMIT F74 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMO <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF U KNOWN <br /> A. OWNER'S TANK 1.0.# B. MANUFACTURED BY: , <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. ❑ ❑ la REGUL R 3 DIESEL <br /> I MOTOR VEHICLE FUEL 4 OIL B. C. F76 AVIATION GAS <br /> ❑ 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUMEd 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADE❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED D 5 JETFUEL <br /> ❑ ❑ 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 ❑ 3 SINGLE WALL WITH EXTERIOR LINEA ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> VILINING 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 ❑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 SUCTION A U 2 PRESSURE AF> GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL U 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)lfuD4 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 ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONERS <br /> RORgJG ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> 7F1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING F74 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING FV 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/OAY/YR) i 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 <br /> (PRINTED a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �(?� !b6- <br /> COUNTY <br /> 9SCOUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT 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--li LOCAL AGENCY IMPLEMENTING THE UNDERGROUND S"' AGE TANK REGULATIONS <br /> FORM B (12-91) 0 % FORMS-R6 <br />