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• STATE OF CALIFORNIA • _ Daces STATE WATER RESOURCES CONTROL BOARD ` a" c UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B /1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ly �41ron M`� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o F G I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) / 170 D. TANK CAPACITY IN GALLONS: a ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A . OTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUNLEADEO ❑ 3 DIESEL ❑ 6 AVIATION GAS ETROLEUM O 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL HEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE O 2 LLE EDD 09g JOTHERL(DESCRIOIN7ITEMT D. BELOW) OT 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 D AND A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL l❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR y LINING ❑ 5 GLASS LINING I�-.XL 5 UNLINED ❑ 95 UNKNOWN ❑ gg OTHER IS LINING MATERIAL COMPATIBLES WITH 100% METHANOL? YES_ NO><- D,CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-1 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILLCONTAINMENTINSTALLED(YEAR)__ a OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A V BARE STEEL p U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING PROTECTION A U 9 GALVANIZED STEELA U 8 100% METHANOL COMPATIBLE W/FRP A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 7I I G ❑ V.TANK LEAK DETECTION MONRORIN99 OTHER ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED D E A USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAININGYES 3.WAS TANK FILLED WITH GALLONS ❑ INERT MATERIAL? ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 4 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW P� 7 O STATE 04COUNTY# JURISDICTION# FACILITY# TANK# m �5 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. •I ��a�� FOg06118-115