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ne P�6.umcm< CQ s STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ele5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED g DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' F� J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANK ONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OILB. C. 1a REGUL D ❑ 3 DIESEL E:] 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ tb PREMIUM ❑ 4 GASAHOL ❑ 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.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ i BARE STEEL ❑ 2 STAINLESS STEEL F-] 3 FIBERGLASS ❑ 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 Ei/95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN E] 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH /0D%METHANOL? YES_ NO D.CORROSION F-� 1 POLYETHYLENE WRAP ❑ 2 COATING V96 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F—] 5 CATHODIC PROTECTION 0 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 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 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIA NTERS I GL ❑99 OTHER MONITV.TANK LEAK DETECTION E 1 VISUAL CHECK F-12 INVENTORY RECONCILIATION ❑ 3 VAPORMONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE E:l 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 APPLICANT'S NAME ---[DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# F-1 17 1 PERMIT NUMBER PERMIT APPROVED BY/DATE 411121?1 CW_ FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROW4B-