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� I((T'1 1 ��C� l/`�'/�- 1, 1 � !!b wuy Ce4 STATE OFCALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY ❑❑ O 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ONE ITEM 2 INTERIM PERMIT DBAOR FACILITY NAME WHERE TANK IS INSTALLED: pn ESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: D.# _ D. TANK CAPACITY IN GALLONS: (MO/DAY YEAR) FiTS IFA-11S MARKED.COMPLE EITEM C. REGULAR H 3 DIESEL ❑ 6 AVIATIONGAS MOTOR VEHICLE FUEL ❑ 4 OIL B. C' ��,JNLEADED 4 GASAHOL 7 METHANOL 1 PRODUCT /"�NLEADED PETROLEUM ❑ 1X1 EMPTY lr.Jrl❑J/ JPREMIUM 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.#: 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED [MATERIAL CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,ANDC,AND ALLTHAT APPLIES IN BOX D AND ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 9]TH OWN F ❑ 1 DOUBLE WALL gR M ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ METHANOL COMPATIBLE WIFRP 5 CONCRETE ❑ e POLWINVL CHLORIDE ❑ 7 ALUMINUMank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ RRUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ OLIC LININGOR 5 GLASS LINING ❑ e UNLINED ❑ 95 UNKNOWN ❑ ERG IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ — D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ GLASS REINFORCED PLASTICPROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ ERE.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION ENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE 99 OTHER A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 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 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 p U 6 CONCRETE p U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION L:] I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 91 NONE 95 UNKNOWN ❑ 99 OTHER ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ ❑ VI.TANK CLOSURE INFORMATION 3.WASTANKFILLED WITH YES ❑ NO ESTIMATED QUANTITY OF 1.ESTIMATED DATE LAST USED(MO/DAV/VR) 2. 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 APPLICANTS NAME (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO TANK# COUNTY# JURISDICTION# FACILITY# - STATE I.D.# L PERMIT NUMBER PERMIT APPROVED 8V/DATE IT 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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORO(WB-Rs FORM 8 (1291) A/�7m