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STATEOFCAUFORMA re`Oo„ o0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. P `'��o-�•' MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF MATION 7 PERMANENTLY ONE ITEM [:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E:] S TEMPORARY TANK CLOSURE ❑ e TANK REMOVED CLOSED O ITE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.i B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) I/t D. TANK CAPACITY IN GALLONS: u�— II.TANK CO S IFA-11SMARKED.COMPLETE ITEM C. A. 71)1S OTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULAR GEADE� 3 DIESEL ❑ g pylATKIN GAS ETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib PREMIUM4 GASAHOLHEMICAL PRODUCT ❑ 95 UNKNOWN a 2 WASTE 2 L ADDED ❑ 5 JET FUEL ❑ 7METHANOL0IN ITEM D. BELOW)D. IOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE 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 INUM ❑ g 100% METHANOL COMPATIBLE W/FRP (PrimeryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 EEPPUNK�NO�WN [—] 99 OTHER ❑ 1 flUBBER LINED ❑ 2 ALKYD LINING ❑ 9 IN I LINING NG ❑ 4 PHENOLIC LINING C.ULTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95/UNKNOWN F__199 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_yyyykKK��NYYYYO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑�L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN O 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U UNKN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p UNKN WN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 5 9RER l4l OTHER MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPORMONITORING❑ 4 AUTOM ANKGAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE ST USED(MO/DAY/YR) 2.ESTIMAD QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO Ll SUBSTANTECE REMAINING .(2j GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRNTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# F LILY# �TANK# � �'ffI FI S STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE AT EXPIRATION DATE FORM 6 (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORDIMMIlIll