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'typuRC< CG STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD +®� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >p COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN TLV CLO N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK RE OVE D�/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.a B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: Q II.TANKCO S IFA-11SMARKED,COMPLETEITEMC. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C. ❑ 1a RE QED 3 DIESEL ❑ B AVIATION GAS , A ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT 10 PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN SOX 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 90 OTHER ❑ 1 RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 FOXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL 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), SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B, CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A=PIPE C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U FIBERGLASS CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U B 100% METHA PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER TIT D. LEAK DETECTION ❑ 1 AUTOMATIC LINELEAKDETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 MONRORINGCDalrOTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 NTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/OAWYR) 2.ESTIMATEDQUANTITYREMAINING OF 3.WAS TANK FIkTERIAL? YES ❑ 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 APPLICANT'S R — 3, DATE 1PRINTED a a1GNAT NAT REI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ^ COUNTY 9 JURISDICTION# FACILITY u TANK 9 I /- 2 STATE I.D.# ® n�n 7- (�0 PERMITNUMBER PERMIT APPROVED BYIDATE PERMITS%PIRATION DATE -7-77r} FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ! , FOR0 BM