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ii�uw'�9 CG • STATE OF CALIFORNIA • s STATE WATER RESOURCES CONTROL BOARD 3 " UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B . . o �y COMPLETE A SEPARATE FORM FOR EACH-TANK SYSTEM. c"'"°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANE OF INFORMATION ❑ 7 PERMANENTLY CLOSED OtLarrE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: !0 7,5-D (-IAl e I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFYIF UNKNOWN A. OWNERS TANK I.D.♦ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) O D. TANK CAPACITY IN GALLONS: /D v II.TANKC TENTS IFA-11S MARKED.COMPLETE ITEM C. REGULAR 1 MOTOR VEHICLE FUEL ❑ A OIL B. C. ❑ 1AUNLEA D 0 DIESEL ❑ g AVIATIONGAS A E❑ 2 PETROLEUM ❑ BO EMPTY 7 PRODUCT ❑ 16PREMIUM a GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 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.0: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A B.ANDC,AND ALLTHATAPPLIES IN BOX A TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ s SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WlFRP (Primary TanY) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNO 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNING ❑ 3,)'Y LINING n 4EMENOLC LINING C.INTERIOR715 GLASS LINING ❑ 8 UNLINED LINING 5 UNKNOWN T�rw OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ NYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ N OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A(L) 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U 5 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U s FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 ST W/COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 NONBORING ❑ 99 OTHER TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATK9N ❑ 3 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING lVV/ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO 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 APPLICANTS NAME DATE (PRINTED&SIGNATURE) / (A LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW q-,7—C'(jM I COUNTY I JURISDICTION I FACILITY I TANK p STATE I.D.# , 6 p PERMITNUMBEfl y PERMIT APPROVED BY/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. �GRO¢Lt&RA