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6�� �C CO STATE OF CALIFORNIA �' o STATE WATER RESOURCES CONTROL BOARD 3 a, o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •,p !<. C�IIFo�M�� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT E] 3 RENEWAL PERMIT CHANGE OF INFORMATON 7 PERMANENTLY CLOSED ON SITE ONE ITEM E-] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (p OO N, 4 I. TANK DESCRIPTION COMPLETE ALL ITEMS—SPECIFY IF UNKNOWN ` A- OWNER'S TANK I.D.# 01/— B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYYEAR) ( / D. TANK CAPACITY IN GALLONS: l� II.TANK CONTENTS IFA-11SMARKED.COMP ITEM C. A ❑ 1 REGULAR MOTOR VEHICLE FUEL 4 OIL B. C• ❑ 18UNLEA ED 8 3 DIESEL ❑ S AVIATION GAS 4 OASAHOL ❑ UM 2 PETROLEUM ❑ 80 EMPTY ❑ 1 DUCT IbUN UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALLTHAT APPLIES IN BOX TYPE OF ❑ UBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. SYSTEM EV 2,G—UE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHEfl ❑ 1 BARE STEEL F-12 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑ 6 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F-12 ALKYD LINING XY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING F-16 UNLINED 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10O%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIC A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTI 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 U A 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 LANK A U 99 OTHER D. LEAK DETECTION ❑1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRTrTLAL ❑ 99 OTHER ORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUT IC TANK GAUGING [_] 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAS USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF ..��/r�� 3.WAS TANK FILLED WITH SUB STA NCE REMAINING V GALLONS INERT MATERIAL? 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 (PRINTED.. N.N.El LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO W COUNTY# JURISDICTION# FACILITY# TANK# { STATE I-D-# 3 . $ I I I I 1 1101/1"', PERMIT NUMBER PERMIT APPROVED BY/DATE IT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.