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• STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD eesoo^ es UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B r o ��' b COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM , o MARK ONLY ❑ I N EW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ICJ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ❑ g TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,5;;�'8 TANK REMOVED 9 I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK 1.1 .D.# OI C. DATE INSTALLED(MO/DAV/YEAR) 1 1 B. MANUFACTURED BY: / 1 1A IS D. TANK CAPACITY IN GALLON! II.TANKCONTENTS IFAIISMARKED,COMPLETEITEMC. A. I MOTOR VEHICLE FUEL ❑ 1 OIL B ❑ 78REOU UNLEA 2 PETROLEUM G 1.31 ED 3 DIESEL ❑ 80 EMPTY '�1 PflODUCT g d GASAHOL ❑ 8 AVIATION GAS ❑ 3 CHEMICAL PgOOUCT ❑ ib PREMIUM ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 6 JET FUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 98 pTMEq (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,ANDC,ANDALLTHATAPPLIES INBOX D C.A.S.#: A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 0 95 SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER UNKNOWN B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS COMPATIBLE W/FRP PLASTIC ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM (Primaryiank) ❑ 9 BRONZE ❑ B 100% METHANOL COMPATIBLEWiFRP ❑ 10 GALVANIZED STEEL ❑ BS UNKNOWN ❑ C.INTERIOR ❑ 1 RUBBER LINED 99 OTHER ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING T9 UNLINED IS LINING MATERIAL COMPATIBLE WITH100% METHANOL? El 95 UNKNOWN El 99 OTHER YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 3 VINYL WRAP El 4 FIBERGLASS REINFORCED PLASTIC BS UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE p U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U I SINGLE WALL A U2 DOUBLE WALL Ag 99 OTHER lu I< C. MATERIAL AND A U I BARE STEEL A U 3 LINED TRENCH p 95 UNKNOWN A V 2 STAINLESS STEEL A 99 OTHER CORROSION A U 5 ALUMINUM 8 CONCRETE A U 7 STEEL A U 3 STEEL NVL CHLORIDE(PVC)p U 4 FIBERGLASS PIpE PROTECTION A U 9 GALVANIZED STEEL A U W/COATING A U 10 CATHODIC PROTECTION A B B 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAKDETECTOR A 95 UNKNOWN A U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORI G'AL �99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ g TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE 12!r95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DA LAS USED(MO__",fl) 2.ESTIMATED OUANTITY OF SUBSTANCE REMAINING IJ GALLONS 3 WASRER7 FILLED WITH VES ❑ NO'�< THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO 774E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IRMNTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I=LDA DNUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Y# JURISDICTION# FACILITY# TAPERMITNUMBIERMIT APPROVED RV/DATE PERMIT E%PIRgTION DATE FORM B (9-90) THISFORMMUST BE ACCOMPANIED BY A PERMITAPPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. �\ `\ FORO9 B0 0