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�boua : c STATE OF CALIFORNIA W� 9 STATE WATER RESOURCES CONTROL BOARD s' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� �cCOMPLETE A SEPARATE FORM FOR EA H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lkr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3-30 I. TANK DESCRIPTION COIAPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYYEAR) D. TANK CAPACITY IN GALLONS: V ILTANKCONTENTS IFA-11SMARKED.COMPLfXEITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OILB. C. ❑ 1aRNGU R 3 DIESEL E:] 6 AVIATIONGAS 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM 4 JETFUECASAHOL ❑ 7 METHANOL ❑ ❑ UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN [-!�MWASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.is 65 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF E] 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM I_4� 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL s CONCRETE F-16 POLYVINYL CHLORIDE F-17 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP ❑ (PfimmyTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F—] 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY LINING E::] d PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YE9_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 81 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 SUCTON A U 2 PRESSURE A03 GRAVITY A U 99 OTHER S. CONSTRUCTION AQp i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 89 OTHER C. MATERIAL AND A U 1 BARE 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 GALVANFED STEEL A U 10 CATHODICPROTECTION p 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK DETECT'1R ❑ 2 LINE TIGHTNESS TESTING ❑ 3 j4pNRORI GL 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN 99 OTHE VI.TANK CL 1.ESTI OA LAST USED(MO/D VIVR) 2 ESTIMATED BSTANCE REMAIINING GALLONS 3WAS INRTMATERIALIP YES ❑ NO T TED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRNTEU a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW aIn 33 COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# lal I of PERMIT NUMBER PERMIT APPROVED SY/DATE PERMIT EXPIRATION DATE FORM B (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS 9BEEN pFILED.