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• 0 �*o-- t <br /> STATE OF CALIFORNIA r r ' t <br /> STATE WATER RESOURCES CONTROL BOARD s4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> ry . <br /> COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED?Q-1%, <br /> ONE REM ❑ 2 INTERIM PERMIT CZ 4 AMEN D P RMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED <br /> ns <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' �1")d <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.0.8 _ B. MANUFACTURED BY: t <br /> C. DATE INSTALLED(MO/DAY/YEAR) + D. TANK CAPACITY IN GALLONS: I-- / <br /> ILTANKCONTENTS IFA-1 IS MARKED,COMPLETEITEMC. <br /> A ( t MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED to REGULAR 3 DIESEL ❑ 8 AVIATION GAS <br /> ❑ 2 PETROLEUM F780 EMPTY 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOI ❑ 7 METHANOL <br /> UNLEADED ❑ 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 AND E <br /> A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK F71 BARE STEEL ❑ 2 STAINLESS STEEL L 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100x. METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESZNO_ <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A1(p 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A@ 2 DOUBLE WALL A U 3 LINED TRENCH A U 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)AQ 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 MONITORING ❑ <br /> 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ t VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> 6 TANK TESTING Se7 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 WITHNO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL S ❑ ❑ <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/ 9 <br /> (PRINTED a SIGNATURE) �j <br /> LOCAL AGENCY USE ONVY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / Q <br /> COUNTY# JURISDICTION A FACILITY#,�tJO TANK* _ <br /> STATE I.D.# m D 0 <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE /IL/ - �� t <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �f <br /> FILE THIS FORM WITH*CAL AGENCY IMPLEMENTING THE UNDERGROUND STO TANK REGULATIONS <br /> CORM 8 (12.91) <br />