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_ STATE OF CALIFORNIA W xp' �3 STATE WATER RESOURCES CONTROL BOARD F's '.c UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B ♦L // COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 7 PERMANENTLY CL SED ON SITE El 3 RENEWAL PANK CLOSURE IT ❑ 5 CHANGE OF INFORMATION 0 , TANK REMOVED 1 NEW PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY T MARK ONLY 2 INTERIM PERMIT ❑ ONE REM DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN 8. MANUFACTURED BY: 3 A. OWNER'S TANK I.D.• D.TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAYtYEAR) ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. ❑ 1a REGULAR 3 DIESEL 6 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. UNLEADED 4 GASAHOL 7 METHANOL O 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT ❑ 10UN UNLEADED ❑ 5 JET FUEL ❑ ❑ 95 UNKNOWN 2 WASTEp El LEADED � 99 OTHER (DESCRIBE IN ITEM D. BELOW) 3 CHEMICAL PRODUCT D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,5,ANDC.AND ALLTHAT APPLIES IN BOXD AND 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) E] 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP MATERIAL ❑ 5 CONCRETE (Primary Tank) E] 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES NO_ le D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP O?r4 FIBERGLASS REINFORCED PLASTIC PROTECTION Q I CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 03 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL p U 3 LINED TRENCH p (f 95 UNKNOWN p U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)CV FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATE ST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERTMATERIAL7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW a COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# 7 o O o D 7 EPERMMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE h V FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNL SSA URRENT FORMA HAS BEEN FILED. Ple case. �, ry iC S z � �� or°