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w `. ST IAmAa „o STATEWATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM B ^ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM- ❑ 7 PERMANENTLY CLOSED ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 8 TANK REMOVED MARK ONLY ❑ 1 NEW PERMIT ❑ ❑ 6 TEMPORARY TANK CLOSURE TQf 2 INTERIM PERMIT 4 AMENDED PERMIT ONE REM .c_ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: A OWNER'S TANK I.D.• C. GATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. le PEa -II UNLEPDED ❑ 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL O 4 OIL B..�( C. ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL �2 PETROLEUM ❑ 80 EMPTY ISL 1 PRODUCT ❑ tc MOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 Q 3 CHEMICALPRODUCT ❑ 95 UNKNOWN �❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE W ITEM D.BELOW) D. IF(A1)IS NOT MARKE). ENTER NAME OF SUBSTANCE STORED C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary TMk) O 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILLCONTAINMENTINSTALLE q) OVERRLL PREVENUIPMENT INSTAL (YEAR) DROP TUBE YES_ NO STRIKER PLATE YES_ NO= DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE ROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I 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 8 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 IECNNNICK UNE IFAK ❑2 ME MiH9 W ❑3 CGMINUGIIS ImEASTRMI ❑4 EIECIRONN MNE 5 AUfOMATW PMP OETEmOR TESTMO MOMTORING [FAIL DETECTOR ❑ SIAIIDDIYN 99 OTTER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 pRE O CILATIONUAL OpY ❑ 3 MONIOZE TORING ❑ 4 GAUGMG AUTOMATIC TANK ❑5 MGROUND ON TORINGTER NNW TESTING❑ 7 MON TORIING INTERSgTIAL ❑ 8 SIR ❑ 9 pryK LY MANUAL [:]10 TESTMONTHLY TANK ❑ 95 UNKNOWN 99 OTHER IN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATE D T USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY M JURISDICTION k FACILITY M TANK p PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLA%LRLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE T.--R�TORAGE TANK REGULATIONS FORM B (6-95) /iy3 FORWN8117 U �;