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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B = COMPLETE A SEPARATE FORM FOR EA TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ a TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Dy DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNEWS TANK L D.# O� R. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/IEAR) D. TANK CAPACITY IN GALLONS: O Ii.TANK Q90TENTS IFA-1 ISMARKEO ITEMC. A. 1 MOTOR VEHICLE FUEL { B. C. ❑ I&REGULAR A ED 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 P T ib PREMIUM { GASAHOL 7 METHANOL a UNLEADED ❑ 5 JETFUEL ❑ ❑ 7 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOW) D. IF(A.1)LR 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 THATAPPLIES IN 13OX0 A TYPE OF ❑ 1 RLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 S WALL ❑ { SECONDARY CONTAINMENT (VAULTED TANp ❑ sp OTHER B. TANK BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ { STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmwyTMJI) ❑ 8 BRONZE ❑ 10 GALVANIZED STEEL ❑ 85 UNKNOWN ❑ % OTHER ❑ 1 RUBBER LINED ❑ 2 LNWG ❑ 3 EPDXY LINING ❑ { P14ENCLC LINING C.INTERIOR LI ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 89 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ r D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 ❑ 3 VINYL WRAP ❑ { FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION1 NONE ❑% UNKNOWN ❑ % OTHER N.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IFUNDERGROUND. CABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U % OTHER B. CONSTRUCTION A U LE—WAZ> A U 2 DOUBLE WALL A U 3 LINED TRENCH A U % UNKNOWN A U 89 OTHER C. MATERIAL AND A U EL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U { FIBERGLASS PIPE CORROSION A U A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL OOMPATIBLE W/FRP PROTECTION A U 8 GALVAMZEO STEEL A U 10 CATHODIC PROTECTION A U % UNKNOWN A U % OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING JML C:3% OTHER MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 WTERSTITIALMONITORING ❑ 97 NONE ❑ 85 UNKNOWN ❑ % OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOCAY/YR) 2.ESTIMATED OUANTITY OF S.WAS TANK FILLED WITH SUBSTANCE REMAINING C GALLONS I NERTMATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (MN Da SIG %MI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 3 1 o PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE FORM B (%gq THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. - FOPOm18a1