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• • nG AP't6V uu+� C w STATE OF CALIFORNIA a 0 STATE WATER RESOURCES CONTROL BOARD w,,,� u a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `an ,, � C�p�pn Yin COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION (� j PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE LTJ/e TANK REMOVEDFlo—fl DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D-# d �_ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 5 D. TANK CAPACITY IN GALLONS: Ji II.TANK C EMS IFA-1 IS MARKED,COMPLETE ITEM C. aREGU AR 3 DIESEL g AVIATION GAS L(A.I)IS R VEHICLE FUEL ❑ 4 OIL B. / C. ❑ UNLEADED ❑ A LrJ/ 4 GASAHOL ❑ 7 METHANOL Ll LEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1bUN EAPREMIDED ❑ 5 JET FUEL ICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) DARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK EITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN 13OXD F7 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN A. TYPE OF 99 OTHER 2 S SYSTEM INGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD Wl FIBERGLASS REINFORCED PLASTIC 8. TANK5 CONCRETE ❑ POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 1 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 AL D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLI D ❑ 96 UNKNOWN ❑ 99 OTHER - LINING IS LINING MATERIAL COMPATIBLE WITH 100% ME ANOL7 VES_ NO— [:] O_❑ 1 POLYETHYLENE WRAP F—] 2 COATING ❑ 3 VINYL WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER _ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UND GROUND,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 i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 85 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL U 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 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTIO A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNE TESTING 3 MONK INIER51 INCL [:]99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORIN 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED p1 IDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO _ SUBSTANCE REMAINING GALLONS INERT MATERIAL 4 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PNNTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# = o PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILET 1y �/;) FOROO B