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0 0 <br />3 RENEWAL <br />PERMIT <br />❑ <br />STATE OF CALIFORNIA <br />❑ <br />STATE WATER RESOURCES CONTROL BOARD <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />PERMIT <br />❑ <br />6 TEMPORARY TANK CLOSURE <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />DONSITE <br />B TANK REMOVED ( <br />��/ N <br />MARK ONLY ❑ 1 NEW PERMIT ❑ <br />3 RENEWAL <br />PERMIT <br />❑ <br />5 CHANGE OF INFORMATION <br />❑ <br />7 PERMANENTLY CLOSED <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ <br />4 AMENDED <br />PERMIT <br />❑ <br />6 TEMPORARY TANK CLOSURE <br />❑ <br />DONSITE <br />B TANK REMOVED ( <br />��/ N <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />- - <br />❑ 7 ALUMINUM <br />❑ 8 100% METHANOL COMPATIBLE W/FRP <br />- <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br />A OWNER'S TANK I. D. # <br />B. MANUFACTURED BY: i <br />C. DATE INSTALLED (MO/DAY/YEAR) r. -+ <br />D. TANK CAPACITY IN GALLONS: <br />II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. <br />A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />C. <br />❑ <br />18 REGULAR UNLEADED F-]3 DIESEL ❑ 6 AVIATION GAS <br />❑ 2 PETROLEUM ❑ 80 EMPTY <br />❑ i PRODUCT <br />❑ 99 OTHER <br />❑ <br />❑ <br />1D PREMIUM UNLEADED E:]4 GASAHOL E]7 METHANOL <br />1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 <br />❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN <br />❑ 2 WASTE <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />❑ <br />2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C, AND ALL THAT APPLIES IN BOX D AND E <br />A. TYPE OF <br />❑ 1 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br />SYSTEM <br />❑ 2 SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />❑ 99 OTHER <br />B. <br />❑ 1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 100% METHANOL COMPATIBLE W/FRP <br />IPTimery Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />LINING OR <br />❑ 5 GLASS LINING <br />❑ 8 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES _ NO- <br />10 CATHODIC PROTECTION <br />D. EXTERIOR <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION <br />ED 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />PROTECTION <br />CEIECTOR <br />TESnM <br />MONITORING <br />CEAK DETECTOR <br />E. SPILL AND OVERFILL, 6CD. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />DROP TUBE YES NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES NO <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. <br />SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE A U <br />3 GRAVITY A U <br />4 FLEXIBLE PIPING A U 99 OTHER <br />B. <br />CONSTRUCTION <br />A U <br />Ii SINGLE WALL <br />A U <br />2- DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. <br />MATERIAL AND <br />A U <br />1 BARE STEEL <br />A U <br />2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />6 CONCRETE A U <br />7 STEEL W/ COATING <br />A U 8 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PROTECTION <br />A U 95 UNKNOWN <br />A U 99 OTHER <br />D. <br />LEAK DETECTION <br />❑ <br />1 MELK44CAL LINE LEAK O <br />2 UNE TGHTNESS O 3 LONTNUWS WIERSTMC O 4 EUiLTiONIL UNE <br />5 AUfOMATC PUMP O 99 OTHER <br />CEIECTOR <br />TESnM <br />MONITORING <br />CEAK DETECTOR <br />SNUi00WN <br />V. TANK LEAK DETECTION <br />❑ 1 VISUAL CHECK ❑ 2 RECONCILATIONANUAL ORV ❑ 3 MONIITORING E]4 GAUGINAUTOMATG <br />TANK ❑ 5 GROUND MONTORINGTER ❑ 6 TESTIINGTANK <br />ANK <br />❑ 7 CONTINU U INTERSTITIAL [DB SIR E]9 WEEK LY MANUAL E]10 MOTESTINGHLY TANK E]95 UNKNOWN ❑ 99 OTHER <br />MITO <br />VI, TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) <br />1. ESTIMATED DATE LAST USED (MOIDAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br />TNI.4 mann HAA RFFN COMPLETED UNDER PENALTY OF PERJURY. AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME DATE <br />(PRINTED A SIGNATURE) <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY # TANK # <br />STATE I.Dl m <br />PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT E%PIRATION DATE <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATILT�ON - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORIC MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br />SHOULD BE ACCOMPANIED BY A PLOT PL#oE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS <br />FORM 8 (6-95) FOR0034&R7 <br />