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�-..' +., •'iT;:.... -.. -._— -e"rf@f'pR"_-"4se.,'/°RT#°."„_T,"�,p."",..;. ,, ,��.'."e'—�..-.-.-.�-.. —. . T-1zTf__'T. � -- we a'lw' .u'."'tel.'t":"��.r:s:'ina. .. <br /> STATE OF CALIFORNIA .P ° <br /> STATE WATER RESOURCES CONTROL BOARD ; g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> •C"l ll.pft H�� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED SIT <br /> ONE ITEM F-12 INTERIM PERMIT E-14 AMENDED PERMIT El6 TEMPORARY TANK CLOSURETANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN <br /> i <br /> A OWNER'S TANK 1.D.# B. MANUFACTURED BY: <br /> f <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br />} IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> 4 A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. Q Ella REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br /> r <br /> ❑ 2 PETROLEUM 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL <br /> ❑ ❑ <br /> t, ❑ tc MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 <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 ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER <br /> B. TANK <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> kMATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> ❑ ❑ ❑ ❑ <br /> LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> I PROTECTION ❑ 5 CATHODIC PROTECTION E:] 91 NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> l SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> j E.SPILL AND OVERFILL,etc- DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <br /> f IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> I <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> i B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> l <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 /> I <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 MECHANICAL UNE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP <br /> DETECTOR ❑ TESTING ❑ MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> I <br /> ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION INVENTORY ❑ 3 VADMONOITORING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER 6 ANNUALTESTING <br />( ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR El9 WEEK LY MANUAL❑ 10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> I( 1.ESTIMATED D!7 LAST (MO/DAY ) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? E] ❑ <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME DATE <br /> (PRINTED 8 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:# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THGROUND STORAGE TANK REGULATIONS <br /> FORM B (6-95) <br /> C <br />