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aao�R e e STATE OF CAUFORMA �° '� STATE WATER RESOURCES CONTROL BOARD + �,� ,.y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR E H TANK SYSTEM " ��""� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS --SPECIFY IF UNKNOWN 770 A. OWNER'S TANK I. D.8 Is B. MANUFACTURED BY: C. DATE INSTALLED (MWDANNEAR) � D. TANK CAPACITY IN GALLONS: 6-660 wv-J6�� 1 _I N TARIV l AKI CARO —.i c11TRMc ❑ 1 MOTOR VEHICLE FUEL OIL A' B. to REGULAR n 3 DIESEL g AVIATION GAS C. ❑ UNLEADED ❑ ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 P UCT LHJ-I 4 GASAHOL ❑ 1bUNEMMIUM ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S.8: III TANK CnNSTRIICTION MAR&NF ITEM ONLY IN BOXES A B. AND C. AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER SINGLE WALL A U 2 DOUBLE WALL A U ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10D% METHANOL COMPATIBLE W/FRP (PrlmvyTmkl ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 LINED ❑ 96 UNKNOWN ❑ w OTHER LINING INTERSTITIAL MONITORING ❑ 91 NONE ON UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL7 YES_ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATI ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF DERGROUNO, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTIO A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNES TESTING ❑ 3NRSII RORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORINGAUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING F-]7 INTERSTITIAL MONITORING ❑ 91 NONE ON UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. )VA DATE LAST USED(MO/DAYNR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING GALLS 3. WAS TANK FILLED WITH INERTMATERIAL7 YES ❑ No THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BES F MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 4 SIGNANRE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# PERMIT NUMBER I 12ERMITAPPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. /�-� FORV9 S-BiM