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r�go <br /> STATE OF CALIFORNIA � p <br /> STATE WATER RESOURCES CONTROL BOARD v ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> ° <br /> COMPLETE A SEPARATE FORM FOR jAfH TANK SYSTEM <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A <br /> I MOTOR VEHICLE FUEL ❑ 4 OIL e. C. ❑ la REGULAR <br /> 3 DIESEL ❑ 6 AVIATION GAS <br /> 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib PREMIUM O 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADED F—] 5 JET FUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.% <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK O t BARE STEEL ❑ 2 STAINLESS STEEL F—] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE � 95 <br /> ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) [—] 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 6 GLASS LINING ❑ 6 UNLINED95 UNKNOWN ❑ 99 OTHER <br /> LINING ly <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATINGW95 <br /> VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 05 CATHODIC PROTECTION E::] 9/ NONE UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH Ad)95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STE !COATING A U 8 100% METHANOL COMPATIBLEW/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 I <br /> NTER TITIA 1:1gg <br /> OTHER <br /> MONV.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES NO E] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED b SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# FyM <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE <br /> FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORMB-R4 <br />