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• 1 . • STATEOFCAUFORNIA ��b��" °>: STATE WATER RESOURCES CONTROL BOARD i '; UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "�� U: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c""°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT E] 9 TEMPORARY TANK CLOSURE dB TANK REMOVED O OBA OR FACILITY NAME WHERE TANK IS INSTALLED: & 3 ', I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.a B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) u� D. TANK CAPACITY IN GALLONS: �Q II.TANKC EMS IFA-7 IS MARKED,COMPLETE ITEM C. A. 7 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ laREGULAR 3 DIESEL UNLEADED 6 AVIATION GAS 2 PETROLEUM 80 EMPTY 7 PROWCT ❑ IDPREMIUM d GASAHOL T METHANOL UNLEADED 5 JETFUEL 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.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALLT14ATAPPLIES IN BOXD A. TYPEOF ❑ 1 DOUBLE WALL E] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE I�I 7 ALPMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmaryTaak) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [1?-f6UUNKNOWN ❑ w OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPyXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING F-1U6 UNLINED ^ 955 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ RO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 MNYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION O 91 NONE 95 UNKNOWN O 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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 5 ALUMINUM A U 6 CONCRETE A U 7 ST L W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 7 AUTOMATIC LINE LEAKOETECTOR ❑ 2 LINE TIGHTNESS TESTING INT ST IAL99 OTHER MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION I:j 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION n, pp�� 1.ESTIMA4D DAT LAST US�(MO/DAVA'R) 2. SUBESTSTANCEMATED REMAININGmoi'/ GALLONS 3 WAS TAN MATEDWII7H YES NO IJP THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE 101COUNTY# JURISDICTION# FAC TANK# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (s90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. fOPa9NB' 0 0