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STATEOFC STATE WATER RSOURCES CONTROL BOARD LIFORMA UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B (/ t o MARK ONLY ❑ 1 NEW COMPLETE A SEPARATE FORM FOR EAC PERMIT ANK SYSTEM ONE REM 3 RENEW ❑ 2 INTERIM PEflM1T ❑ AL PERMIT ❑ CHANGE OF INFORMATION ❑ ❑ 7 ERMANENTLV CLOSED 4 AMENDED PERMIT 8 TEM TANK CLOSURE DBA OR FACILITY NAPE WHERE TANK IS INSTALLED: 6 TANK REMOVED I. TANK DESCRIPTION14 N COMPLETE ALL ITEMS.- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# C. DATE INSTALLED(MQ/DAYrypgR) B. MANUFACTURED BV: D. TANK CAPACITY IN GALLONS: 11.TANKC ENTS IFA-11SMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL B. ❑ 2 PETROLEUM a REGULAR ❑ 80 EMPTY C. UNLEADED 3 DIESEL O 6 AVIATIONGAS 1 PRODUCT ❑ 10 PREMIUM 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ ❑ 7 METHANOL D. IF(A.1)ISNOTMARKED, ENTER N5 JETFUEL OF SUBSTANCE STORED ❑ 2 LEADED ❑ 5 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXESA.8 AND C,AND ALL THAT APPLES——.IBODANDE C.A.S.#: FSYST7EM Ua DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 2 SINGLE WALL ❑ 95 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 OXY LINING E_] 4 PHENOLIC LINING C.INTERIOR ❑ LINING 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATINGINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE . SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. PTERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE KCORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D.. LEAK DETECTION L] 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORING ❑99 OTHER ANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 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/DAVryR) 2.ESTIMATED QUANTITY OF 3.WASTANKFILLED WITH VES ❑ NO ❑ SUBSTANCE REMAINING GALLONS IN MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE �y 3 (PRINTED 8SIGNATURE) �(J�u� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMB ELOW COUNTY# JURISDICTION CILITY# TANK# STATE I.D. j y?j PERMIT NUPERMIT APPROVED BV/DATE DATE O TRS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. a FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) 1�