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w STATE OFCAUFORNIA ±�'•-•••,' r_ STATE WATER RESOURCES CONTROL SO AAD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B / h v COMPLETE A SEPARATE FORM FOREACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY, SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D I. TANK DESCRIPTION COMPLETEALLREMS- SPECIFYIFUNKNOWN A OWNERS TANK I.O.s B. MANUFACTURED BY: C. DATE INSTALL IMO/OAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANKC2LUENTS IF 11 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ a OIL B. C. aUNLEA�OED }--.I 7 DIESEL ❑ 8 AVUTICN GAS ❑ 2 PETROLEUM ❑ s0 EMPTY 1 PRODUCT ❑ TCPREMNM U s µOL ❑ 7 METHANOL UNLEADED 5 JET FUEL 7 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN REM 0, BELOM 0. IF(A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S t III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES AB.ANO C.ANOALL THATAPPUES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 7 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 ❑ 7 FIBERGLASS ❑ A STEELCLAOW/FIBERGLASSREINFORCEOPLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING C:] 7 EPDXY LINING ❑ a PHENOLIC LINING C.INTERIOR ❑ 5 CLASS LINING ❑ 8 UNLINED LINING ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 7 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION a S CATHODIC PROTECTION Q 91 NONE a 95 UNKNOWN a 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 7 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 7 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHCOICPROTECTICN A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ C II IAL ❑ 99 OTHER MCNRORIIG V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 7 VAPOR MONITORING❑ a AUTOMATIC TANKGAUGING ❑ 5 GROUND WATER MCNITCRING ❑ 8 TANK TESTING ❑ 7 INTERSTITALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 0714ER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LASTUSEO(MO/DAY/YR) 2.ESTIMATEOOUANTTY OF 7.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT.MATERIAL7 YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPUCANTSNAME GATE IPCINTEO A sl J mPq LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 5 Zy-CQUNTY A JURISDICTION 8 FACILITY X TANK S STATE I.D. � �W 2 6 U PERMIT NUMBER /��7 PERMIT APPROVED BY/pATE PERM IT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED 3Y A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORamNBM L '