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STATE OF CALIFORNIA �° °°i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "�� »° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. "�� MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GAL S: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. I g 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Kl'bLIPREMIUM N'RELEADED G LA ❑ 3 DIESEL ❑ 6 AVIATION GAS s❑� 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT 4 GASAHOL ❑ 7 METHANOL NLEADED ❑ 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL AT APPLIES IN BOX D AND A. TYPE OF j0 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXT IOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAI ENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHL IDE ❑ 7 ALUMINUM ❑ 8 100% M THANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANRED TEEL ❑ 95 UNKNOWN 9 OTH ❑ 1 RUBBER LINED ❑ 2 ALKYD LIN G ` ❑ 3 EPO LI G P OLK: ING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINE N O LINING IS LINING MATERIAL COMPATIBLE IT 1 AN L7 N D.CORROSION ❑ 1 POLYETHYLENE WRAPG 4 FIBERGLASS R INFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTIO T11ONE "51:' NO N ❑ 99 OTHER / E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLE (YEAR) OVERFILL PREVENTION EGUIPMENT INSTALLED(YEAR) / r6 IV.PIPING INFORMATION CIRCLE A IF ABOVE ROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A®2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A®4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM // A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Illgf 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 KT RSTITLAL ❑ 99 OTHER MoERORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING ] INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATI N 1.ESTIMATED DATE LAST USED(MO/DAV R) 2.ESTIMATED OUANTITYOF 3.WAS TANK FILLED WITH SUB STANCE R EMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COM LETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE 0 Y THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# inn TANK#OO STATE I.D.# m = 131 O / PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FIL JA ws-w='*No V '40"o-�'A=ae"