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STATE OFCAUFORMA ` f STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE # TANK REMOVED O G DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O# B. MANUFACTURED BY: qA G� w C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS V ILTANKCONTENTS IFA-1 ISMARKED.COMPLETE ITEM C. MOTOR VEHICLE FUEL ❑ 4 OIL B. C 14 REGULAR Ed 3 DIESEL ❑ 6 AVIATION GAS A UNLEADED 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ tOUNLEADED O 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED o 99 OTHER (DESCRIBE IN ITEM 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 A,B.AND C.AND ALLTHAT APPLIES IN BOX D AND rMATERIAL F1�-yyI� DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN 5<2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL S FIBERGLASS ❑ 4 STEEL CLAD W/FIRE REINFORCED PLASTIC ` ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHAN�L ' �,TIBLE W/FRP k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHERN'1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING . R ❑ 5 GLASS LINING ❑ 6 UNLINED A5 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION UNKNOWN ❑ 99 OTHER I E.SPILL AND OVERFILL SPILL CONTAINMENT IN LED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNOERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A Vi SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A UNKNOWN A U 90 OTHER C. MATERIAL AND A U 1 BARE STEEL A D 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 STEE W/COATING A U 0 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A UNKNOWN A U W OTHER D. LEAK DETECTION E] 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING F-1MONITORING ❑99 OTHER V.TANK LEAK DETECTION ��// FTF- 6 ISUALCHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING IST 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE T❑l 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM jjJ. USi.BF�D(MO AVIVR) n 2.ESTIMATED REMAINING 3.WAS TANK FILLEDWITHI Y ❑ Ip� �/ (O SUBSTANCE QUANTITY GALLONS INERT MATERIAL? THIS FORM HAS BEEN COM ETED UNDER PENALTY OF PERJURY,AND TO THE B T OF MY NOWLEDGE, IS TRUE AND CORRECT TS NAME DATE jNAT �✓ , L!YUSEONLY T STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COU NITY# JURISDICTION# FACILITY � TANK# TE I.D.# m l� PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS wRomMtro FORM B (1291) \/