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coua e STATE OFCAIJFORNA .c '"•,, STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERM ENTLY C O ITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TAN REMOVE O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CA I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN �6 37 A. OWNER'S TANK I.D.# B. MANUFACTURED BY: I C. DATE INSTALLEO(M AY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CO NTS IFA-11SMARKED.COMPLETE ITEM C. MOTOR VEHICLE FUEL ❑ 4 OIL 9, C ❑ 1a REGULAR DIESEL ❑ 6 AVIATION GAS A. UNLEADED 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT O 1bUq EAOED ❑ 5 JET FUEL ❑ ]METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UN1010WN ❑ 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.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 AL M ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 ENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING j 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 96 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMAT14 CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH FAPPLICABLE A. SYSTEM TYPE yuj 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U W OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORID (PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM p U 'e CONCRETE A U 7 W/COATING A U 8 100% METHANOL COMPATIBLE WFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION e U A UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TITSTING 31Ni STI IAL MONITORING ❑W OTHER V.TANK LEAK DETECTION ❑ VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING[7] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 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( _/ 2 LOCAL AGENCY USE��..'�,,�nn�ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 490-4- 01 COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D. M 10101 / 1 PERMITNUMBER PERMIT APP DBY/DATE PERMIT E%PIRATION DATE FORM 8 (SI THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. RXiO¢146R1