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YyOUR STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B uo COMPLETE A SEPARATE FORM Fna FArW TANK CVSTFM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDMSiTE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 7/4 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ANN% U=k;KIY I IUN COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. N B.C. B. MANUFACTURED BY: e C. DATE INSTALLED (MO/DAY/YEAR)- ❑ lb PREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL D. TANK CAPACITY IN GALLONS: ❑ 2 WASTE II. TANK CONTENTS IFA -1 IS MARKED.COMPIPTF ITFMr A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.C. is REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTYFell' PRODUCT ❑ lb PREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 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. u III. TANK CONSTRUCTION MARK nNF ITEM nNI VIN RnYFR A a ANn r ANn AI I TLJAT ADDI ICC IAI OnV n AAIn C A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 5Z3 FIBERGLASS E]4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3INTERSTITIAL ❑ ❑� RUBBER LINED F-]2 ALKYD LINING ❑ 3 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING �J 6 GLASS LINING ❑ 6 UNLINED E-195 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP E;K4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN a 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND OR U IFLINnFRrRnuNn RnTHIFAPPI Ir.ARIF A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE p rxGRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AG) 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U p U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A 0 7 STEEL W/COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3INTERSTITIAL ❑ MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION 0 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE 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 1. ESTIM T DTE LAST USED (MO/DAY/VR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH YESNO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND F Y N EDGE, IS TRUE AND CORRECT APPLI�AWTS NAME _ f DATE iw LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF4E FOUR NUMB! ELOW COUNTY # JURISDICTION # FACIL Y # TANK # 10 STATE I. D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATEvv / 7/ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BtENFILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12.91) FOR0034 BR6