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a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P6MANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE rc, B TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED:5 j fol o F I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• 8. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 4 Wo ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. A. 1a REGULAR 3 DIESEL 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ UNLEADED ❑ e AVIATION GAS F-14 GASAHOL 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 70UN EADED ❑ ❑ 7 METHANOL 5 JETFUEL ❑ 3 CHEMICALPRODUCT r2 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED a 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOXD A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (PrlmanJTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3�EPDXY LINING ❑ d PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED UNKNOWN99 OTHER LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_yJNN1O_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING [:] 3 L WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION O 5 CATHODIC PROTECTK)N ❑ 91 NONE 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 U 9 OTHER B. CONSTRUCTION A U I 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 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ACU 5 UNKNOWN A U 99 OT R D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORINOLOTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VA R MONITORING E] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMAT DDATE LASTU D O/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �. SUBSTANCE REMAINING GALLONS INERT MATERIAL YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATDRE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACIL TANK# STATE LDAm 3 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN JFI D FOO`RROMB-694 • • V