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U. � STATE OF CAUFORMA �..i �` STATE WATER RESOURCES CONTROL BOARD e�+. - t UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "�� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM c-`��°""�� MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMITANGE OF INFORMATION 7 E ENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT 714 AMENDED PERMIT 6 TEMPOPARY TANK CLOSURE K REMOVED c DBA OR FACILITY NAME WHERE TANK IS INSTALLED: } l/ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: ei II.TANKCO NTS IFA-11SMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ is REGUL EPD 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ID PiiEM1UM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNW40WN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF IA.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.s: - 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I DOUBLE WAIL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [;/YSTNGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK �ST REEL ❑ 2 STAINLESS STEEL I❑ 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM a 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN Q 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED C�q "JRINOWN ❑ 99 OTHER LINING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEEl UNKNOWN O 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICP CTION kID5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETEC"1R 2 LINE TIGHTNESS TESTING ❑ 31M'pNRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VI HECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING ❑'S GROUND WATER MONITORING �T/ANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER T VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/)AYNR) 2.ESTIMATED OUANTTTY OF 3.WAS TANK FILLED WITH YES E] 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 APPLICANTS NAME DATE IPNNTED8WANREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Tle / II LLCOUNTY# JURISDICTION# FACILITY# TANK# y/�STATE 015C lg&Q S PERMITNUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE _ / FORMS 19.901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 78-PA