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rt6 Y4 CO UR STATE OF CALIFORNIA � Ar >A STATE WATER RESOURCES CONTROL BOARD S C , / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B !� COMPLETE A SEPARATE FORM FOR5pCH TANK SYSTEM. MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENrE CLQ IT ONE ITEM [�/2 INTERIM PERMIT ❑ 4 AMENDED PRM IT� ❑ 6 TEMPORARY TANK CLOSURE E::] 8 TANK REMD DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.>Y B. MANUFACTURED BY: C. DATE INSTALLED(MO Y/YEAR) D. TANK CAPACITY IN GALLONS: 190 6) �) v ✓J II.TANK CO NTS IFA-1 IS MARKED,COMPLETE ITEM C. a REGULAR 3 DIESEL A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED ❑ ❑ 6 AVIATION G ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM D 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.s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D A. TYPE OF �O UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [+- 2 GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK BARE STEEL F—] 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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 E pdx Y LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED EAX UNKNOWN -❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION F--] 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E:] 91 NONE 5 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE Sae4D OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A Lk,11 SUCTION A 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 99 OTHER C. MATERIAL AND A V 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 B 100°/ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTIN 3 MONITORI GL 0 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITO GAUT MATIC TANK GAUGING E] 5 GROUND WATER MONITORING El TANK TESTING L:] 7 INTERSTITIAL MONITORING E] 91 NONE ❑ 95 KNOWN ❑ 99 OTHER 7 3 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 APPLICANTS NAME DATE (PRINTED 6 SIGNATURE) / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.DA y7i COUNTY# JURISDICTION# FACILITY E TANK# O PERMIT NUMBER PERMIT APPROVED B /DATE PERMIT EXPIRATION DATE FORM B (9.90) THII FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. \/,� FOR0034B•R4 0 \ i