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ow y STATE OF CALIFORNIA ;� STATE WATER RESOURCES CONTROL BOARD ;aw4e� y o UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B -,.� ,ry o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK L0.0 W 4 B. MANUFACTURED BY: oo1�- C. DATE INSTALLED(MONAYATAR) D. TANK CAPACITY IN GALLONS: OQ II.TANK CONTENTS IFA-1 IS MARKED.COMPLIETE ITEM r- ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ laUNGU 0uR 8 3 DIESEL ❑ 8 AVIATION GAS A. ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 10PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRU ON MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS [pr4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 5 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LININGLININGF75 GLASS LINING El UNLUNLINEDr2loo UNKNOWN 1:199 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A V 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A U 10 CATHOOICPROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTK)N 1 AUTOMATIC LINE LEAK OETECTOR ❑ 2 LNETIGHTNESS TESTING ❑ J NONROR G ❑90 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK o /NVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING LLLJJJ�00�/7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO(DAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES E] NO SUBSTANCE REMAINING GALLONS NERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT APPLICANTS NAME DATE IPRINTED 6 SlWMTURE7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 8 FACILITY 9 TANK 9 STATE I.D.#CNEUR I3 ® Ill © PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE Fo a ta90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. _ R710161N8Aa ��.