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STATEOFCAUFORIMA STATE WATER RESOURCES CONTROL BOARD ` .o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B id COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT pfr 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E:;4� TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D,x 2- B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: S S fJH.'X� II.TANK C!ONTENTS IFA-1 IS MARKED.00MPLETEITEM C. ��{ A. U MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ILI eUNLEADED 3 DIESEL ❑ g AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ 10PREMIUM 4 GASNOL ❑ 7 METHANOL ❑ F—] 9 CHEMICAL PRODUCT ❑ BS UNKNOWN UNLEADED 5 JET FUEL 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF �❑�l DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER F795 UNKNOWN SYSTEM 1� 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER S. TANK PW!l ' RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pri=yT=k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C I TENOR F—] 6 GLASS LINING ❑ 6 UNLINED R-95 UNKNOWN ❑ 99 OTHER LIN IS LINING MATERIA COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ;�wf41 NONE ❑ 95 UNKNOWN O 99 OTHER IV.PIPING INFORMATION CIRCLE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTIE A IF ABOVE ON A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A®B 1012% METHANOL COMPATIBLE WTAP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR E7rl LINE TIGHTNESS TESTING ❑ 9 MON RORING L ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK [.o y 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING F-15 GROUND WATER MONITORING �6 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED D;TE LAS SED(MO DAV/YR) 2.ESTIMATED STANCE REMAINING O GALLONS 3 Wg INERT MATERIALTANK FILLEDI7H YES E:]SUBNO /� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRNTED 8 SIGNATUREt LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# JM&T"1 STATE I.D.# "—I © p Ala - PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATON DATE ae /-3- ' Z FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORO9M&M V