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quit STATE OF CALIFORNIA Mr . STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B COMPLETE A SEPARATE FORM FORCH TANK SYSTEM. MARK ONLY Q 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION E:] 7 PERMANENTLY C TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.# B. MANUFACTURED BY: 01 C. DATE INSTALLED(MO/DAY/YEAM D. TANK CAPACITY IN GALLONS: 11.TANK C!eENTS IF A-1 IS MARKED,COMPLETE ITEM C. r--j la REGU A. [PIl MOTOR VEHICLE FUEL 4 OIL C. I❑I A 3 DIESEL ❑ 6 AVIATK)NGAS 2 PETROLEUM ❑ 80 EMPTY O!r�IPRODUCT UNLE 4 GASAHOL lb PREMIUM 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT Q 95 UNKNOWN LEADED E:l 2 WASTE ED 2 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.III: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALL THAT APPLIES IN BOX D A. TYPE OF I DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM /?!'2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I RARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 65 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE io GALVANIZED STEEL E] 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED El 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING F-] LINING 5 GLASS LINING ❑ 6 UNLINED ❑ 96 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— D.CORROSION ❑ I POLYETHYLENE WRAP F-1 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IF A80VE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 2 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 I STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7STE W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION zu ,5 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESdTESTTING E] 3 INTERSTITIAL MONITORNG [:]99 OTHER_ V.TANK LEAK DETECTION HF-�L 1 VISUAL CHECK F-� 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING F-� 4 AUTOMATIC TANK GAUGING 6 GROUND WATER MONITORING [:] 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE El 95 UNKNOWN E] 99 OTHER , 22 I VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 7 NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO 774E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.DA 10-7 PERMIT NUMBER PERMIT APPROVED 8Y/DATE PERMIT EXPIRATION DATE FORM 8 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.