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STATE OFCAUFORNA •`pOH° ` STATE WATER RESOURCES CONTROL BOARD c i+ UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ' ` o . . o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM n [MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMITONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE 8 TEMPORARY TANK CLOSURE O 8 TANK REMOVED A OR FACILITY NAME WHERE TANK IS INSTALLED: 2- 1 t 46f I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# /i S. MANUFACTURED BY: C. DATE INSTALLED(MO(DAY/YEAR) bo K D. TANK CAPACITY IN GALLONS: D II.TANK CONT S IFA-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OILB. G ❑ I-AEGUUNLEAAR 8 3 DIESEL 8 AVIATION GAS ❑ 2 PETROLEUM ❑ W EMPTY PROOUCT ❑ 1b PREMIUM 4 GASAHOL O UNLEADED n`� 5 JET FUEL 7 METHANOL ❑ 3 NOTM MARKED. ❑ 95 UNKNOWN O 2 WASTE 2 LEADED LJ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.0.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.BAND C,AND ALLTHATAPPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 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 O 4 STEEL CUD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 LINING ❑ 4 PHENOL%: LINING C.I TEING IIOR a 5 GLASS LINING E:] 8 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 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�' GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A OZ"93 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 B 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 if:IP UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ T IN NORING RS A 99 OTHER MOIT V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 98 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LA T USEO 4/ AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E:] NO 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 APPLICANPS NAME (PRMTEO 8 SIGNGiUREI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# � PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE e.7– FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 6 // crf FOROmObW�//�) Now y /