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' • STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD 4. '? UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 4. � COMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SI ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE '❑ 6 TANK REMOVE / DBAOR FACILITY NAME WHERE TANK IS INSTALLED: / / 0 la s , //yL' 1 \,1� 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN G \W A. OWNER'S TANK 1.D. B. MANUFACTURED BY: o/c _ C. DATE INSTALLED(MO/DAYNEAR) -- D. TANK CAPACITY IN GALLONS: �� "'y'I ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. P.�. C. *,,a IREGU R 8 4 DIESEL I � 6 AVIATION GASA 2 PETflOLEUM ❑ BO EMPTV �1 PRODUCTDUN PREMIUM ❑ 5 JETFUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) O. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF K I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL X3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ N OTHER ❑ 1 RUBBER LINED �❑y 2 ALKYD LINING ❑ 3 EPCXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 'w 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING /-\ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES X NO D.CORROSION ❑ I 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 IFABOVEG UNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U N OTHER B. CONSTRUCTION A U I SINGLE WALL DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U N OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U N OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINETIGHTNESSTESTING 3MONRORING ❑ N OTHER V.TANK LEAK DET TION F❑ 1 VISUAL CHECK F72 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ED GROUNDWATER MONITORING ❑ 6 TANK TESTING 7 IN.ERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN C:] N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMA Ir LAST S D(MO/DAY/YR) ( 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRIMED!SIGNATURE) LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# r�� STATE I.D.# p 6 PERMIT NUMBER I 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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM (12.91) c/ e`C J�1� • � FORODNB116