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w � STATE OF CALIFORNIA „ w..•°V STATE WATER RESOURCES CONTROL BOARD �---AMERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S Ccs d XY s 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN WK I.D. S. MANUFACTURED BY: C. DATE INSTALLED(MODAY/YEAR) u� D. TANK CAPACITY IN GALLONS: lJ 11.TANK C ENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. E�r-REGUUNLEALAR 3 DIESEL B AVIATIONGAS ❑ 2 PETROLEUM ❑ SO EMPTY ❑ 1 PRODUCT ❑ tb PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADE❑ 3 CHEMICALPROWCT ❑ 95 UNKNOWN El WASTE ❑ 2 LEADED D 99,OTHER (DESCRIBEIN ITEM 0.BELOW) D. IF(Ai)IS NOT MARKED, ENTER NAME OF SUBSTANCE STOREO C.A.S.A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF F--] 1 BLE WALL F73 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK f BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL OOMPATISLE W/FRP (PAmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING N LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ECTK)N PROTECTION ❑ 5 CATHODIC PROT91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLK:ABLE A. SYSTEM TYPE A U S A U 2PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U t A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL W/COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U W OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ] 2 LINE TIGHTNESS TESTING ❑ MoNOOANG ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ZE MONITORING ❑ AUTOMATIC TANK GAUGING E_—] 5 GROUND WATER MONITORING �❑ S TANK TESTING O 7 INTERSTITIALMONITORING 91 E UNKNOWN ❑ 99 OTHER A.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED WANTITY OF 3.WAS TANK FILLED WITH l /s�y SUBSTANCE REMAINING GALLONS INERTMATERIAL7 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY s JURISDICTION s FACILRV A TANK STATE I.DA F-3141 = I I Ia S �7 PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FCRM A HAS BEEN FILED. / " FORMS-R5