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0 9 STATE OF CALIFORNIA " STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: If TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IFA -1 IS MARKED. COMPL2 fE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL A. ❑❑ B. 1. REG LAR C. a 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY❑ 1 PjiODUCT ❑ 1bPREMIUM UNLEADED ❑ 4 GASAHOL ❑ 5 JETFUEL ❑ 7 METHANOL F-]3 CHEMICAL PRODUCT ❑ 95 UNKNOWN (�fal 1/f/WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED t..7I ❑ 7 ALUMINUM C. A. S. #: (Primary Tank) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F-]2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ,❑ ED5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 9 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A& GRAVITY A U 99 OTHER B. CONSTRUCTION sp1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A p UU A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL W/ COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3'MONITORINTE ING IAL ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN iric 99 OTHER T/7.N kbu VI. TANK CLOSURE INFORMATION 1. ES M TE ATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO E7:1SUBSTANCE REMAINING GALLONS INERT MATERIAL ? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED & SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.#,31fc. PERMIT NUMBER I PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. L FOR0034B-115