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�souR e c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD w „� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , COMPLETE A SEPARATE FORM FOR E H TANK SYSTEM. MARK ONLY 0 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ITE ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED 11,51 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY FUNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MOIDAY/PEAR) D. TANK CAPACITY IN GALLONS: A ❑ I MOTOR VEHICLE FUEL 6 OIL B. C. ❑ 18UNLEA ED 4 GASNOL ❑ 8 AVIATX)N GAS ❑ 2 PETROLEUM ❑ 80 EMPTY A. TYPE OF SYSTEM Ib PREMIUD F-15 JET FUEL ❑ 7 METHANOL UNLEAD3 CHEMICAL PRODUCT 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. i : III TAAIY/PnAICTOIICTInM Li ov nuc i=u nNI v IN 9nXF9 A R ANn C. ANn AI I THAT APPI. IFS IN BOX Iv. I DOUBLE WALL 33 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM 2 SINGLE WALL ^� �4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER cu -lb BARE STEEL ❑ 2 STAINLESS STEEL F73 FIBERGLASS [1]4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 2 STAINLESS STEEL A U ❑ 1 RUBBER LINED n Z ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ��-4, UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 10D% METHANOL COMPA BLEW/FRP LS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO- A U D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER Iv. rlrmu Hvrvmmm nvr, uncls q Ir Revvcu A. SYSTEM TYPE A U 1 SUCTION cu -lb PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 10D% METHANOL COMPA BLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN AtQ99 O ER IZa D. LEAK DETECTION 0 I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRTITIA 99 OTHER J. TAN LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN O 99 OTHER 1. E;SUB TI D DATE LAST USED (MO/DAY/YR) I 2 ESTIMATED REMAINING GALLONS 3 WASIN RT MATERIALTANK FILLED I7H YES ❑ 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 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACIL TANK It STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B 1490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. PM04BR4