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� ;M-o of U ST- �CAi�u'U� ^�eovaces STATE OF CAUFORNLA STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B . il COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �" ole MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PE MANENTLITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 T K REMOV D�r7` DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (% I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I_D.AA B. MANUFACTURED BY: C. DATE INSTALL (MO/DAY/YEAR) i D. TANK CAPACITY IN GALLONS: 11.TA^ EWS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C. ❑ 1aUNGU ED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ❑ ib cMIUlm 4 GASAHOL ❑ 7 METHANOL �16❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE 2 LEADED 5 JET FUEL DEO ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER A. TYPE OF ❑ ❑ ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PrlmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ._ ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING a 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR a 6 GLASS LINING ❑ 6 UNLINED F-195 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH iDo% METHANOL 7 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 1 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 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D, LEAK DETECTION [71 AU70MATCLINE LEAKDETECTOR O 2 LINE TIGHTNESS TESTING ❑ 3 LAL bpNROI'G ❑99 Oh1ER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING C, 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MON!TORINC ❑ 6 TANK TESTING ❑ 7 INTERSTITtALMON ITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI,TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2_ESTIMATED OUANTrrY OF 3.WAS TANK FILLED WITH YES NO n SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNATURE) i LOCAL AGENCY USE ONLY THE STATE I.D,NUMBER IS COMPOSED OF E FOUR NUMBERS BELOW COUNTY z JURISDICTION4 FACILITY# TA # PERMITNUMBER PERMIT APPROVED B TE ERM ITEXPIRATIO ATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A,UNLESS A CUR ORM A HAS BEEN FILED.