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• STATE OF CAUFORMAnecooncy STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B �� e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. •Cn(nOn Min MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ❑ 8 TEMPORARY TANK CLOSURE O e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /200/ a�f �L/a�cccc I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.N 8. MANUFACTURED BY: C. DATE INSTALLED(MO/OAY/YEAR) U D. TANK CAPACITY IN GALLONS: OHO II.TANK NTENTS IFA-11SMARKED,COMPLETE ITEM C. A. FVJ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR 3 DIESEL/ ❑ 2 PETROLEUM ❑ I-7/y UNLEADED 8 ❑ 8 AVIATION GAS 80 EMPTY Ua• 2 5 JET FUEL 7 METHANOL PRODUCT ❑ IbPREMIUM GASAHOL UNLEADED ❑ ❑ 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.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX 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 ❑ I BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER LINING 6 UNL ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR F-1GL 5 ASS UNLINED ❑ ❑ LINING ❑ E] D6 UNKNOWN ❑ 90 OTHER IS LINING MATERIAL COMPATIBLE WTTH 100%METHANOL 7 YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ g1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICA13LE A. SYSTEM TYPE A U 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 A U 95 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 6 CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL 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 ❑ 3 INTERS ING WE]L 99 OTHER MONROR V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR 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 DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES 0 NOD THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE 1.0.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 41i STATE I.D.# L/c �2 PERMIT NUMBER PERMIT APPROVED BY/DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. e FORD==-RI \