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azo ^ ea NW 9TAT[OFCALIFORMA STATE WATER RESOURCES CONTROL BOARD n UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKN WN A. OWNER'S TANK I.D.• O� B. MANUFACTURED BY: v^oe C. DATE INSTALLED(MO/DAYIYEAR) `' D. TANK CAPACITY IN GALLONS: 442-12 ILTANKCO S IFA-11S MARKED.COMPLETE ITEM C. A1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Ir I BREGLILAR UNLEA ED 3 DIESEL ❑ 6 AVIATIONGAS 712 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL O 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN O 2 WASTE O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D- BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 52-12 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE 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 (PrimaryTank) O 9 BRONZE ❑ 10 GALVANIZED STEEL F2�95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING LINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3VIVINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE I?95 UNKNOWN ❑ 98 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p 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 UNKNOWNA U 99 OTHER C. MATERIAL AND A U 1 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 U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A®a5 UNKNOWN A U 99 OTHER D. LEAK DETECTION Q<AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ MDNRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING &14 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ' COUNTY# JURISDICTION# FACILITY* TANK# STATE I.D.# 37 F-71 = I I I I Ill li 131f( PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE \ I\ FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. O ' FORM11415