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• ae STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 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 CLOSED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a 3 6 G I. TANK DESCRIPTION COMPLETE ALL ITEMS--SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: u _ C. DATE INSTALLED(MO/DAY/YEAR) �' D. TANK CAPACITY IN GALLONS: �'O ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. ❑ / MOTOR VEHICLE FUEL 1�4 OIL B. C. ❑ la REGULAR 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑-T80 EMPTY ❑ 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL ❑ UNLEADED ❑ 5 JET FUEL ❑ ❑ 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 L(JaS/L C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND 3 SINGLE WALL W 1 DOUBLE WALL WITH EXTERIOR LINER A. TYPE OF ❑ ❑ 95 UNKNOWN SYSTEMj� 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) [:j99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimeryTok) ❑ 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 LINING � 99 6 UNLINED ❑ 95 UNKNOWN ❑ OTHER �( _ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NOK D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 ❑ MONITORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING 6 TANK TESTING O 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DA E S U5 p(MO/DAY/YR) 2.ESTIMATED QUANTITY OF w 3.WAS TANK FILLED WITH �j S SUB STANCE REMAINING ""GALLONS INERTMATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED b SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Ae'c' 1 COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH FORME (12-91) 6LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST AGE TANK REGULATIONS � FOR