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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s` ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> ry <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 2ri CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br /> A. OWNERS TANK 1.D. S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYIYEAR) D.TANK CAPACITY IN GALLONS: <br /> II.TANKCONTENTS IFAMI IS MARKED.COMPLETE ITEM C. <br /> t ULAR <br /> MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ /4UN LEADED B 3 DIESEL ❑ S AVIATIONGAS <br /> A 4 GASAHOL <br /> ❑ 2 PETROLEUM ❑ 90 EUM <br /> MPTY 21 PR O JUNLEIbPREDED 5 JET ❑ 7 METHANOL <br /> ❑ 3 CHEMICALPRODLICT ❑ 96 UNKNOWN ❑ 2 WASTE �^f LEADED ® 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.4: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOXD <br /> A. TYPE OF ❑ 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL ❑ <br /> (PdMWVTMk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL d95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING ❑ 8 UNLINED O q'5UNKNOWN ❑ 99 OTHER <br /> LINING <br /> L4 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ <br /> O.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3,VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Erm UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AW95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U B GALVANIZED STEEL A U 10 CATHODIC PROTECTION A UNKNOWN p U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTEIiSTITLAL MONRORNG 9B OTHER Ouj <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORINGTOMATIC TANK GAUGING❑ 5 GROUNDWATERMONITORING <br /> ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> t.ESTIMATED DA � (MO/DAY/YR) zESTIMATE000ANTTfYOF 3.WASTANK FILLED WITH YES NO <br /> G Sl1BSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> IVPoNTEDA SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 1 f- G "(,( <br /> FORMS (4M THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. // <br /> FORMS <br /> �r ' <br />