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a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B E COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED ONSITE MARK ONLY O 1 NEW PERMIT 6 TEMPORARY TANK CLOSURE a TANK REMOVED ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: n n I. TANK DESCRIPTION COMPLETE ALL SPECIFY IF UNKNOWN B MANUFACTURED BY: A. OWNERS TANK I.D.# D. TANK CAPACITY IN GALLONS: C. DATE INST LLED(MO/DAYNEAR) II.TAN ENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1a REGULAR O 3 DIESEL ❑ 6 AVIATIONGAS 1 TOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ UNLEADED ❑ 4 GASAHOL A SO EMPTY 1 PRODUCT 1b PREMIUM ❑ 7 METHANOL PETROLEUM ❑ UNLEADED ❑ 5 JETFUEL 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 ai III. TANK CONSTRUCTION MARK ONE ITEM ONLVIN 80XES0.B,AND C,AND ALL THAT APPLIES IN BOX ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF 4 SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ALUMINUM ❑ 6 100% METHANOL COMPATIBLE WIFRP MATERIAL (PfimaryTank) O 9 BRONZE RUBBER LINED ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER 2 ALKYD LINING ❑ FOXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ go OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ INYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ ❑ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE B5 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 3 GRAVITY A U 99 OT B. CONSTRUCTION A U 1 SINGLE WALL' A U 2 DOUBLE WALL A U 3 LINED TRENCH p U UNKNO ptCOMPATIBUE ER C. MATERIAL ANO A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS CORROSION A U 5 ALUMINUM A U 6 CONCRETEA U 7 STEELW/COA A U B 100% METHAW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 9 NKNOW A U 99 OTHER 71MERSTITIAL 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST jM1Oj)) 2.ESTIMATED OUANTITY OF VES ❑ NO 'L (O SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TE APPLICANTS NAME IPRINTEn a SIGNFTIIRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBEW COUNTY# JURISDICTION# FACILITY# TANK# STATE 013Ty PERMIT NUMBER PERMIT APPROVED BV/DATE RMIT 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. FOIIOIXINV&M • � l