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4f,*UR @9 STATE OF CALIFORNIA .P ...... ca A STATE WATER RESOURCES CONTROL BOARD < o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �� . hill. COMPLETE A SEPARATE FORM FOR EACH T STEM ^�IFppN MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE 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. OWNER'S TANK I.0.X 8. MANUFACTURED BY: C. DATE INSTALLED( DAY/YEAR) D. TANK CAPACITY IN GALLONS: v II.TANK CO NTS IF A-1 1S MARKED,COMPLETE ITEM C. A. MOTOR VEHICLE FUEL ❑ 4 OIL8. C• UNLEADEDREGULA3 DIESEL g AVIATION GAS ❑ 2 PETROLEUM F--] 80 EMPTY 1 PRODUCT ❑ ib PREMIUM U 4 GASAHOL ❑ 7 METHANOL UNLEADED Ed 5 JET FUEL ❑ 3 CHEMICAL PRODUCT Q 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.$ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D A. TYPE OF ❑ 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER ❑ B. TANK i BARE STEEL ❑ 2 STAINLESS STEEL E] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALU M ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) 9 BRONZE E:] 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED g' ❑ 2 ALKYD LINING ❑ 3 EPO KING ❑ 4 PHENOLIC LINING C.INTERIOR a LINING 6 GLASS LINING rn 6 UNLINED UNKNOWN ❑ 99 OTHER r' IS LINING MATERIAL COMPATIBLE WITH 100%-METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 WR ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTIONE:] 91 NONE 5 UNKNOWNAP 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A IAS A u 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 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/C IG A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 LVANIZED STEEL A U 10 CATHODIC PROTECTION A 95 UN WN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 AdT S IAL MONITORING [:] 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 IN TORY RECONCILIATION 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING F-� 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST US EO(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH � zz SUBSTANCE REMAINING /0! GALLONS I INERT MATERIAL? YES E NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# ;TATE LD.# L.L_L_L_ PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS CURRENT FORMA HAS BEEN FILED. FOROM104)