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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 4 w Via, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE 1 ❑ 8 T MARK ONLY ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED ONE ITEM El2 INTERIM PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G 7 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN B MANUFACTURED BY: A. OWNER'S TANK I. D. D. TANK CAPACITY IN GALLONS: D� r–>C. DATE INSTALLED (MOIDAYIYEAR) II. TAN KCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. ❑ taREGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS F71 MOTOR VEHICLE FUEL 4 OIL B. C. UNLEADED 4 GASAHOL ❑ 7 METHANOL A. 5�, t PRODUCT ❑ lb PREMIUM 5 JET FUEL 2 PETROLEUM F780 EMPTY UNLEADE 1:1D 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) [:] 3 CHEMICAL PRODUCT El D. IF (A.t) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALLTHAT APPLIES IN BOX D AND E 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ 99 OTHER SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC 1-7 t BARE STEEL B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER (Primary Tank) ❑ 9 BRONZE ❑ ❑ t RUBBER LINED ,,-❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ a PHENOLIC LINING C. INTERIOR 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 5 GLASS LINING LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ N ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION F7 g1 NONE 5 CATHODIC PROTECTION ❑ E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p U 95 UNKNOWN A U 99 OTHER FIBERGLASS PIPE C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U IN L CHL RIDE (PVC) A U a IBE METHANOL COMPATIBLE W/FRP CORROSION A U S ALUMINUM p U 6 CONCRETE A U 3 STEEL95 UNKNOWN A U 99 OTHER PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 9 MONRORING U 99 OTHER V. TANK LEAK DETECTION F-1 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 99 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING El 91 NONE ❑ 95 UNKNOWN VI. TANK CLOSURE INFORMATION 3. WAS TANK FILLED WITH YES ❑ YNo ❑ 2. ESTIMATED QUANTITY OF GALLONS I INERT MATERIAL? 1. ESTIMATED DATE LAST USED (MO/DA/YR) SUBSTANCE REMAINING D UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDDG , IS TRUE AND CORRECT THIS FORM HAS BEEN COMPLETE APPLICANTS NAME (PRINTED b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK # COUNTY # JURISDICTION st FACILITY # 1 d 3 el STATE I.D.# hj rT PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED.; 0- .�F�oo�as as FORM B (7-91) /%p(/