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• • STATE OF CALIFORNIA Vp �' STATE WATER RESOURCES CONTROL BOARD ° NF s° o?*o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �-l��On N,n MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ ❑ ❑ 7 PERMANENTLY CLOSED ONSITE 4 AMENDED PERMIT ❑ g TEMPORARY TANK CLOSURE �6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: d DG I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN ° A. OWNER'S TANK I.D.• B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ❑ 1.REGULAR C. O 3 DIESEL ❑ 6 AVIATIONGAS 2 PETROLEUM ❑ SO EMPTY Tv1'j pgOOUCT ❑ 1b PREMIUM ❑ 4 GASAHOL 1�� UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 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.#: III. TANK CONSTRUCTION MARKONEITEMONLYINBOXESA,B.ANDC,ANDALLTHATAPPLIESINBOXDANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 85 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING x6 UNLINED ❑ 95 UNKNOWN 99 OTHER ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP -- ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE Ej 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U1 SUCTION A U 2 PRESSURE A 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 U 99 OTHER C. MATERIAL AND A U T SPIPE AME STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS CORROSION A U 5 ALUMINUM A U 6 CONCRETE p U 7 STEEL W/COA71N0 PROTECTION A U 9 GALVANIZED STEEL p D 10 CATHODIC PROTECTION A U 8 100% METHANOL COMPATIBLE W/FRP ------------------- A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONMOMING ®99 OTHER Q V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING [D6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 81 NONE ❑ 85 UNKNOWN 14 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAS USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING3.WAS TANK FILLED WITH YES ❑ NO�Q'I GALLONS INERT MATERIAL? ��ll THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, APPLICANT'S NAME IS TRUE AND CORRECT (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW r) D COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# m �-m q- :PEMIT NUMBER PERMIT APPROVED BY/DATE ALL-LLJ_J PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BE FILED. O FILE THIS FORM WITH AGENCY IMPLEMENTING THE UNDERGROUND ST GE TANK REGULATION FORME (12-91) ao-9 �