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• STATE OF CALIFORNIA • <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />COMPLETE A SEPARATE FORM FOR EACH TANK RYRTFM <br />A. OWNER'S TANK I. D. a 013 B. MANUFACTURED BY: Ag Y!l <br />C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS' u <br />Gil <br />I= <br />A. u✓ 1 MOTOR VEHICLE FUEL <br />❑ 4 'LB. <br />I— ILL. my I nrrLI[. In bUA. U ANUt <br />C 1a REGULAR <br />UNLEADED <br />3 DIESEL <br />❑ 6 AVIATION GAS <br />a 2 PETROLEUM <br />❑ 80 EMPTY <br />1 PRODUCT <br />1b PREMIUM <br />4 GASAHOL <br />❑ 7 METHANOL <br />❑ 3 CHEMICAL PRODUCT <br />E:]95 UNKNOWN <br />❑ 2 WASTE <br />NLEADED <br />❑ 5 JET FUEL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 700% METHANOL COMPATIBLE W/FRP <br />2 LEADED <br />❑ 99 OTHER (DESCRIBE <br />IN ITEM D. BELOW) <br />D. IF (A.1)IS NOT MARKED, ENTER NAME <br />OF SUBSTANCE STOPED <br />C. INTERIOR <br />❑ 1 RUBBER LINED❑ <br />2 YD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />LINING <br />C. A. <br />8 UNLINED <br />••• • •• •••.. •••vmm�..vn UIRULt A Ir ABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br />B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 6)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)A U 4 FIBERGLASS PIPE <br />CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U a 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ABS UNKNOWN A U 99 OTHER <br />D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING3 <br />❑ IMN(T)ERSTITWU ❑ 99 OTHER <br />V. TANK LEAK DETECTION <br />❑1�VVSUAL CHECK L6 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br />6 TANK TESTING ❑ 7 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 GALLONS INERT MATERIAL? YES ❑ NO❑ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY ANn Tn TNF PPQT nF AAV WA1nMAl cnnc <br />APPLICANT'S NAME <br />(PAINTED a SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMRFR IR enMPnorn ng TUC enuo r, I., <br />STATE LD.# COUNTY# JURISDICTION# FACILITY# TANK# <br />PERMIT NUMBER PERMITAPPROVED BY/DATE PERMITEXPIRATION E w -7 <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED. <br />CECT <br />FORM B (12-91) <br />FILE I nIa runm WI I n I nt LUCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />• • A. <br />/G FOROa16&R6 <br />v <br />❑ UBLE WALL <br />I— ILL. my I nrrLI[. In bUA. U ANUt <br />A. TYPE OF <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 95 UNKNOWN <br />SYSTEM <br />2,WIGLE WALL <br />❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) <br />❑ 99 OTHER <br />B. TANK <br />/ BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 700% METHANOL COMPATIBLE W/FRP <br />(PrimaryTank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />C. INTERIOR <br />❑ 1 RUBBER LINED❑ <br />2 YD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />LINING <br />❑ 5 GLASS LINING <br />8 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES_ NO— <br />D. CORROSION <br />❑ 1 POLYETHYLENE WRAP <br />2 COATING❑ <br />3 WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />95 NOWN <br />UNKL <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />nr nlnn.n u <br />••• • •• •••.. •••vmm�..vn UIRULt A Ir ABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br />B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 6)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)A U 4 FIBERGLASS PIPE <br />CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U a 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ABS UNKNOWN A U 99 OTHER <br />D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING3 <br />❑ IMN(T)ERSTITWU ❑ 99 OTHER <br />V. TANK LEAK DETECTION <br />❑1�VVSUAL CHECK L6 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br />6 TANK TESTING ❑ 7 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 GALLONS INERT MATERIAL? YES ❑ NO❑ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY ANn Tn TNF PPQT nF AAV WA1nMAl cnnc <br />APPLICANT'S NAME <br />(PAINTED a SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMRFR IR enMPnorn ng TUC enuo r, I., <br />STATE LD.# COUNTY# JURISDICTION# FACILITY# TANK# <br />PERMIT NUMBER PERMITAPPROVED BY/DATE PERMITEXPIRATION E w -7 <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED. <br />CECT <br />FORM B (12-91) <br />FILE I nIa runm WI I n I nt LUCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />• • A. <br />/G FOROa16&R6 <br />v <br />