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STATE OF CAUFORMA � he y <br /> STATE WATER RESOURCES CONTROL BOARD g <br /> N UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "�� �� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM e""°"���. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT r74 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 0`9 <br /> n <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.x B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: D <br /> II.TANK NTENTS IFA-i IS MARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C. ❑ 18REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY V/, PRODUCT 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADED ❑ 5 JET FUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 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.a: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA.B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER EY'95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR <br /> ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 9 UNKNOW <br /> A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/C A U 8 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 9 UNKNOW A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 31NTERSTITIAL <br /> MONRORING ❑gg OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 UTOMATICTANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATES U' ( AV R) 2.ESTSUBIMATED STANCE REMA11 NG GALLONS TY OF 001/ 3 WASTANK FILLED NERT MATERIAL)?H YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BE[OW <br /> COUNTY# JURISDICTION# ACILITY# TANK# <br /> STATE I.D.# g top/ <br /> PERMITNUMBER PERMIT APPROVED BY/DATE IT EXPIRATION !!__°0 <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMrr APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR0814B R4 <br /> 0 0 9 j <br />