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�` uP ° STATE OF CALIFORNIA "• °°^ STATE WATER RESOURCES CONTROL BOARD g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B m`� �o COMPLETE A SEPARATE FORM FORE CH TANK SYSTEM. '"°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EE1115 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE50rrE ONE REM F—] 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEDDBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS–SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# R. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: D ILTANKCO ENTS IFA-11SMARKEDCOMPLETEITEMC. 1 MOTOR VEHICLE FUEL E] 4 OIL B. C. 19u NEA�RD 3 DIESEL ❑ g AVIATIONGAS A E::] 2 PETROLEUM ❑ g0 EMPTY PRODUCT O 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ UNLEADED 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2LEADEDL ❑ 99 JOTHER (DESCRIBE IN ITEM D. BELOW) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑�/1/p'p UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM w � GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK1 BARE STEEL 172 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrlmwyTw*) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER F—] 1 RUBBER LINED ❑J2D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GUM LINING 8 UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 PoLYETHYLENE WRAP ❑ 2 TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLAS? REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION LU,.Cl NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AW SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AV 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 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP 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 O 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL ❑ 99 OTHER MONITORING V.TANK LEAK DETECTION qRp E7ISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 V R MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING :] 6 ANK TESTING ❑ 7 INTERSTITIAL MONITORING �fT1 LAf"NNONE ❑ 95 UNKNOWN ❑ 98 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOiDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED!SIGNAWRE) 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 PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (9.9) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0036994 5 11o