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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />1. IANKUESCHIPIION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I. D. B. MANUFACTURED BY: <br />C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br />I nlvn bvl\ 101110 IF A-1 IS MARKED,COMPLETE ITEM C. <br />A. 1 MOTOR VEHICLE FUEL O 4 OIL <br />S. <br />C. � 1eUN REGULAR3 DIESEL 8 AVIATIONGAS <br />2 PETROLEUM O BO EMPTY <br />�1 PRODUCT <br />O ib PREMIUM 4 GASAHOL Ej 7 METHANOL <br />0 3 CHEMICAL PRODUCT 0 95 UNKNOWN <br />0 2 WASTE <br />UNLEADED 5 JET FUEL <br />O 2 LEADED <br />0 1 BARE STEEL <br />ID 2 STAINLESS STEEL <br />O W OTHER (DESCRIBE IN REM D. BELOW) <br />D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. s <br />111. TANK CONSTRUCTION MACN n.c.Tr. nu. � �..�� . a .— <br />A. TYPE OF <br />1 DOUBLE WALL <br />O 3 SINGLE WALL WITH EXTERIOR LINER <br />O 95 UNKNOWN <br />SYSTEM <br />O 2 SINGLE WALL <br />O 4 SECONDARY CONTAINMENT (VAULTED TANK) <br />F-1 99 OTHER <br />B. TANK <br />0 1 BARE STEEL <br />ID 2 STAINLESS STEEL <br />O 3 FIBERGLASS <br />O 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />O 5 CONCRETE <br />O 8 POLYVINYL CHLORIDE <br />7 ALUMINUM <br />8 100% METHANOL ODMPATIBLE W/FRP <br />(PrimaryTNk) <br />0 9 BRONZE <br />E:j 10 GALVANIZED STEEL <br />95 UNKNOWN <br />F-1 99 OTHER <br />4 FIBERGLASS PIPE <br />O 1 RUBBER LINED <br />O 2 ALKYD LINING <br />3 EPDXY LINING <br />0 4 PHENOLIC LINING <br />C. INTERIOR <br />O 5 GLASS LINING <br />E] 8 UNLINED <br />O 95 UNKNOWN <br />F--1 99 OTHER <br />IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? <br />YES_ NO— <br />9 GALVANIZED STEEL <br />D. CORROSION <br />0 1 POLYETHYLENE WRAP <br />O 2 COATING <br />[:] 3 VINYL WRAP <br />O 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />F --j 5 CATHODIC PROTECTION 0 91 NONE <br />O 95 UNKNOWN <br />O 99 OTHER <br />1V. YIYINL9 IN�UKMA I ION clone •m nvoneni e....eu <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 />99 OTHER <br />B. <br />CONSTRUCTION <br />A U <br />1 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 <br />4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />a CONCRETE A U <br />7 STEEL W/COATING <br />A U <br />8 100% METHANOL COMPATIBLE WIFRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PROTECTION <br />A U 95 UNKNOWN <br />A U <br />99 OTHER <br />D. <br />LEAK DETECTION <br />[::] 1 <br />AUTOMATIC LINE LEAK <br />DETECTOR Q 2 LINE TIGHTNESS TESTING L 31 R ML <br />99 OTHER <br />-j MONITORING <br />I ANK LEAK DETECTION <br />[:j 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION E] 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORIN( <br />❑ 8 TANK TESTING O 7 INTERSTITIAL MONITORING 0 91 NONE 95 UNKNOWN O 99 OTHER <br />n. rnnn V6wou IC Uirvm1Y1M 11VN <br />1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br />SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES NO <br />THIS <br />rvnryHAa occly COMPLETED UNucnFENAL—ryPtH✓uH, <br />ANU FO THE HEST OF MY KNOWLEDGE, IS TRUE AND CORF <br />APPLICANTS NAME <br />IVRINTEDB SIGNATUFE) DATE <br />LOCAL AUENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />STATE LD.# <br />COUNTY# JURISDICTION# FACILITY# TANK# <br />PERMIT NUMBER PERMIT APPROVED BY/DATE <br />FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. <br />?ECT <br />