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• • '4440a � f STATE OF CALIFORNIA = 'o STATE WATER RESOURCES CONTROL BOARD W,�� .v a UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B 'e, ,„ a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ��TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: v./L- A. OWNERS TANK I.D.# C/, , U D. TANK CAPACITY IN GALLONS: ppp C. DATE INSTALLED(MOIDAY/YEAR) ILTANKCONTENTS IFA-11S MARKEO.COMPLETE ITEM C. aREGU AR 8 3 DIESEL ❑ B AVIATION GAS LIF MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ UNLEADED 4 GASAHOL 1 PRODUCT ❑ 1DPREMIUM ❑ 7 METHANOL PETROLEUM ❑ 80 EMPTY -UNLEADED 5 JETFUEL CHEMICAL PRODUCT ❑ 95 UNKNOWN ,❑ 2 WASTE LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) NOT MARKED, ENTER NAME OF SUBSTANCE STOPED C.A.S. III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.NDALL THAT APPLIESIN BOXD ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPEEM ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ OTHER SYSTEM ❑ 2 SINGLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING XV LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 ASS LININ ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER CL LINING IS UNIN MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION p5 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER E.- 3 A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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 S ALUMINUM A U 6 CONCRETE p U 7 STE L W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U 99 OTHER [:]D. LEAK DETECTION 1 AUTOMATIC LINELEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ a kWF6Po GL ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 SUBSTANCE QUANTITYWATED F BSTANCE REMAINI GGALLONS INERT MATERIAL 7 YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGEE IS TRUE AND CORRECT APPLICANT'S NAME IPRNTED a W"AWFE1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# [=KKE PERMITNUMBERERMIT APPROVED.,,DATE PERMIT EXPIRATION DATE Ler FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILLED.