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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD ;y.,.. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY O SITE ONE REM INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REM D n DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION OMPL TE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.a S. MANUFACTURED BY: C. DATE INSTALLED(MO'DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK ENTS IFA-I ISMARKED.COMPLETE ITEM C. i UNLEADED 8 REGULAR 3 DIESEL ❑ A. 1 MOTOR VEHICLE FUEL ❑ a OIL B. C. ❑ S AVIATIONGAS PFIEMIUM 4 GASAHOL ❑ 2 PETROLEUM ❑ 8O EMPTY �1 PRODUCT IGUNLEAD D a 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEAOEp o 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 A. TYPE OF I❑ 11 7UBLE WALL F73 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM I� 2 LE WALL ❑ < SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL (—] 3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100'% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING �XY LINING ❑ K PHENOLIC LININ,G/ C.INTERIOR ❑ 5 GLASS LINING ❑ B UNLINED 95 UNKNOWN ❑ 90 OTHER (/� LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP n 2,,COATING ❑ 3 VINYL WRAP ❑ 4 F18ERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION �f'2 991 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.80TH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION AR 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 U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U M FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U .S CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ O MONRORINGL ❑99 OTHER V.TANK LEAK DETECTION �71 CHECK CR2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ W 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? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANTS NAME DATE (MICTEO!SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY K JURISDICTION x FACILITY A TANK STAT I.D. D 1 U PERMIT NUMBER PERMITAPPROVEp BY/DATE lj PERMR EXPIRATION DATE FORM B (9-9M THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROPJ4B N