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�.o STATE Of CALIFORNIA �� •� of STATE WATER RESOURCES CONTROL BOARD ; S UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �� ya •, ,. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �""O"'�� MARK ONLY a I NEW PERMIT a 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION O 7 PERMANENTLY CLO ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DSA DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (k w I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a B. MANUFACTURED BY• C. DATE INSTALLED(MOIDAWYEAR) D. TANK CAPACITY IN GALLONS: If.TANK CO NTS IF A•1 IS MARKED.COMPLETE ITEM C . 1� ;4 A 1 MOTOR VEHICLE FUEL ❑ A OIL 19, D to REGULAR 3 DIESEL 5 AVIATIONGAS UNLEADED A OASAHOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ iDUN PREMIUM .6 U 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. E(A.11 IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A8,AND C.AND ALL THAT APPLIES IN BOX A. TYPEOF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O A STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE 10 GALVANGED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING a a PHENOLIC LINING C.INTERIOR ❑ 5 GLASB LINING 8 UNLINED ❑ 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WRH 100%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNOOR U IF UNDERGROUND.BOTH IF APPLICABLE A 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 TRENCH A U 95 UNKNOWN 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 A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a 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 A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINETIGHTNESS TESTING ❑ 3 MDNRORING ❑ OTHER V.TANK LEAK DETECTION F❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION [:] 3 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONRORING C::] 91 NONE ❑ 96 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO(DAY/YR) 2.ESTIMATED QUANTITY OF 3.W ❑ N AS TANK FILLED WITH YFS O❑ SUBSTANCE REMAINING GALLONS INERTLIATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE IMNTED A SIGMA AM LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY x TANK x STATE LD. �c p � a a PERMIT NUMBER PERMITAPPROVEDBY/DATE PERMIT EXPIRATION DAT / FORM B (%Ba) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FoaaaHBw ,/