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• ecooN e STATE OF CALIFORNIA ' ` STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ^mom o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �""°""��' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT F7 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED //c - DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.If B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) IfM/ D. TANK CAPACITY IN GALLONS: / ILTANK C TENTS IFA-1 IS MARKED,COMPLETE ITEM C. 7 MOTOR VEHICLE FUEL ❑ 4 OIL B. O. ❑ Te RE DPO n 3 DIESEL ❑ 6 AVIATIONGAS A ❑ 2 PETROLEUM O 80 EMPTY 1 PRODUCT PREMIUM IL=�1� 4 GASAHOL ❑ 7 METHANOL UN �DE ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEAOEDD ❑ 99 JET OTHERFUEL (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, EN R NAME OF SUBSTANCE STORED !) C.A.S.0: III. TANK CONSTRU ION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLVS IN BOX A. TYPE OF IV 7 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LI R 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT ULTED TANK) ❑ 99 OTHER B. TANK F-] 1 BARE STEEL E::] 2 STAINLESS STEEL EV3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 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 UNLINED ❑ 95 UNKNOW ❑ 99 OTHER LINING ,I,,,lwfi/' IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO a -/ 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 AIFABOVEGR RGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION p 2 PflESSUR A U 3 GRAVITY p U 98 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U DOUBLE WALL p 3 LINED TRE p U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A 6-3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3INTERSTITIAL ❑ 99 OTHER MONRORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DAT LAST USE (MOIDAV/VR) 2.ESTIMATEOOUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAININO GALLONS INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PAINTED a SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMITNUMBEflI PERMIT APPROVED BV/DATE PERMIT EXPIRATION-DATE -�ZJ FORM B (9 90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION -FOR/MM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 00 �� FOROAWB'