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e$ou. <br /> STATE OF CALIFORNIA P ... <br /> STATE WATER RESOURCES CONTROL BOARD <br /> �t i g <br /> ROUND STORAGE TANK PERMIT APPLICATION <br /> UN -FORM B 4�� <br /> COMPLETE A SEPARATE FORM FOR EAC <br /> HW SYSTEM "°" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED !^} <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L c�c{ C✓ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> 11.TANK C ENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ t�PREMIUM <br /> 3 DIESEL ❑ 6 AVIATION GAS <br /> 4 GASAHOI2 PETROLEUM ❑ 80 EMPTY 1PRODUCT i7 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 ARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF ❑ 1,06USLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 M ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN .„.-- ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED - F--] 2 ALKYD LINING ❑ 3 E LINING ❑ 4 PHENOLIC LINING <br /> C.INLININIGR ❑ 5 GLASS LINING ❑ 6 UNLINEDff—G� 96 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES._ NOs <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VI AP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A2 PRESS A U 3 GRAVITY <br /> A U 99 OTHER <br /> B. CONSTRUCTION A U / SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINU A U 6 CONCRETE A U 7 STEE <br /> A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9_qAeVXNIZED STEEL A U 10 CATHODIC PROTECTION C'AH 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 i ❑E .I11IAI 99 OTHER <br /> M <br /> V.TANK LEAK DETECTION ONRORNG <br /> ❑ 1 VISUAL CHECK ❑ 2 INVE RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING 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 WITH <br /> SUBSTANCE REMAINING INERT MATERIAL? YES ❑ NO <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 <br /> (PRINTED&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 P RMIT EXPIRATION DATE <br /> FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOROai4B R4 <br />