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• STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD iy b UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ©TANK REMOVED C! DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D. 5 -0 B. MANUFACTURED BY: C. DATE INSTALLED(MOIOAY/YEAR) V D. TANK CAPACITY IN GALLONS: A II.TANK EMS IFA-11S MARKED,COMP TE ITEM C. A. MOTOR VEHICLE FUEL 4 OIL B. C ❑ to HhUULAN ED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 ROOUCT ❑ 1D PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.#: D� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF �❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM IAV�2 5 LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK Ep-l"BARE STEEL F--12 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINEDUNKNOWN 99 OTHER LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_�NNyO_ D.CORROSION F71 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 V L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION ❑ 91 NONE S UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY p U =99 B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A NOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p 5 UNKNOWN A D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECT"R ❑ 2 LINE TIGHTNESS TESTING 3INTERSTITIAL Va .1..,�MONITORING �l�I V.TANK LEAK DETECTION MEl1VISUA6 L CHECK F—] 2 INVENTORY RECONCILIATION E] 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM ED DATE LAST U O/ (MDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH r SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# PERMITNUMBER T 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. Pt)