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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B ama COMPLETE A SEPARATE FORM FOR ,fAC'H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED F DBA OR FACILITY NAME WHERE TANK IS INSTALLED: W, 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. I a REGULAR 3 DIESEL 2 PETROLEUM ❑ 80 EMPTY I PRODUCT UNLEADED H 4 GASAHOL ❑ 6 AVIATIONIGAS ❑ lb PREMIUM 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT 96 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.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D A. TYPE OF 1 DOUBLE WALL E] 3 SINGLE WALL WITH EXTERIOR LINER E:] 96 UNKNOWN SYSTEM ❑ 2 SINGLE WALL E 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. 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 COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD LINING F-� 3 EPDXY LINING F-14 PHENOLIC LINING F-� LINING 5 GLASS LINING ❑ 6 UNLINED F--j 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING F--j 3 VINYL WRAP F--j 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E:] 5 CATHODIC PROTECTION [:] 91 NONE 95 UNKNOWN J:�jk 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE qRNND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION q L2PRESSIURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A(UJ2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I 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 100%METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN u OTHER D. LEAK DETECTION [:] I AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING E] 3 INTFA L-TORNG 0 99 OTHER MONI V.TANK LEAK DETECTION ❑ I VISUAL CHECK6 20 INVENTORY RECONCILIATION E] 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ TANK TESTING k7 NTERSTITIAL MONITORING El 91 NONE ❑ 96 UNKNOWN ❑ 1 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH I YES SUBSTANCE REMAINING GALLONS INERT MATERIAL? NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT aPPucarlrs AE IRE) DATE I LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STAE to COUNTY# JURISDICTION# FACILITY# TANK# Lo lo P F43T/7 PERMIT NUMBER PERMIT APPROVED BY/DATE ERMIT EXPIRATION DATE FORM B (9-gq THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FORoas1B•PA