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\� STATE OF CALIFORNIA �: ^�```•�"• STATE WATER RESOURCES CONTROL BOARD g UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B C- oNM- COMPLETE ASEPARATE FORM FOR EfiegTANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN Y CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [-] e TEMPORARY TANK CLOSURE ❑ 8 TANK REM VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4Q4LU eff I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: L( C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11SMARKED.COMP ITEMC. A ❑ 1 MOTOR VEHICLE FUEL Ee4 OIL S. C. ❑ 18 REGULAR H 3 DIESEL ❑ 8 AVIATION 6A3 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 DUCT ❑ ihMIUUNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 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 ALL THAT APPLIES IN BOX A. TYPE OF ❑ UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL E] 2 STAINLESS STEEL ❑ 3 FIBERGLASS E714 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE E] e POLYVINYL CHLORIDE ❑ y.U/A 7 )NUM ❑ B 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL95/UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING C.IN F-15 GLASS LINING 8 UNLINED F-195 UNKNOWN E] 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO_ D.CORROSION F-] 1 POLYETHYLENE WRAP ❑ 2 ATING f7 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U RAVITY 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 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 D. LEAK DETECTION F-1 1 AUTOMATIC INE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORING IERSTITAL ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING[:j4 AUTOMATIC TANK r.AUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITV OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERTMATERIALT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE )PRINTED 8&G.ATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 5pwc ro STATE I.D.# = I I I ./I<f O PERMIT NUMBER I IPFRMITAPPROVED BV/DATE PERMIT 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. �FORMB-RN