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• • STATE OF CALI FORMA Ae eeco°"" e>r STATE WATER RESOURCES CONTROL BOARD ; e�' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� s COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. "°""��. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED ON SITE ONE ITEM F-] 2 INTERIM PERMIT O 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE a TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 56 ILTANKCO TENTS IFA-11S MARKED,COMPLETE ITEM C. 1aUNLEADED ❑ A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 4 DIESEL 6 AVIATION GAS REGULAR L ❑ 2 PETROLEUM ❑ 80 EMPTY I/y„1 PRODUCT ❑ bPREM1UM ❑ ❑ 7 METHANOL —` UNLEADED O JOTHERL(DESCRIBE IN ITEM D. BELOW) 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN � 2 WASTE � 2 LEADED 99 D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ON ITEM ONLY IN BOXES A.B,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 1 BARE STEEL STAINLESS STEEL ❑ 3 F18ERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 LYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrIm9ryTAnk) ❑ 9 BRONZE ❑ 10 LVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKY LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINE ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH IOD%METH OLP YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND ORUIFUNDEROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A 3 LINED TRENCH A U 95 UNKNOWN AU 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETEC-nR ❑ 2 LINE TIGHTNESSTES G 3 MONITORING ❑TITIAL 99 OTHER MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING F77 INTERSTITIAL MONITORING ❑ 91 NONE ❑ IS UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DL T USED( /DAV/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO '�, � ATE� ...� SUBSTANCE REMAINING GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# l I _ I I I = PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED _ FORDIX B-R4