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eF 50Yuy e0 STATE OFCALIFORMA e s STATE WATER RESOURCES CONTROL BOARD iy '; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� as . . o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o 2 L47-- 1. _- I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.N I B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) , D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-IISMARKED,COMPLETEITEM C. A, O 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ 1a REGU R 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ m EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL El UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION RK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL 2 STAINLESS STEEL F-1 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (PrimmyTmk) ❑ 9 BRONZE ❑ 10 LVAN�D STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ / RUBBER LINED ❑ 2 ALKY LINING ❑ 3 EPDXY LINING 0 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANO YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) VERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF UCABLE X SYSTEM TYPE A U 1 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 TRENC A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORI (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 U 95 UNKNOWN U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ jN'rr`ORBJG 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VAD02E MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 6 HOUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION -�im 1.ESTIMA DATE ST USED(MO/DAV/YR) 2.ESUBSTATED NCEQREMAININGUANTITY F V GALLONS 3 WASNERT MATERIAL TANK FILLED 7H YES ❑ NOD THIS FbRM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATIRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD,# 3� IZ131t I5 S E3 l S S 8 0 PERMIT NUMBER 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 TI•-'OCAL AGENCY IMPLEMENTING THE UNDERGROUND STOP-,E TANK REGULATIONS FORM (12-91) %wool N%w4 `�/�� FDN02k8-N6