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.eeou^ � °o STATE OF CALIFORNIA ' 0 STATE WATER RESOURCES CONTROL BOARD 'mom' >�. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED DNSIT] MARK ONLY q AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED ONE ITEM 2 INTERIM PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: 4(/j)!�/ A. OWNERS TANK I.D.# /z " h D. TANK CAPACITY IN GALLONS: V (p C. GATE INSTALLED(MO(DAYlVEAR) II.TANK ENTS IFA-11SMARKED.COMPLETEITEM C. IaREGULAR 3 DIESEL ❑ 6 AVIATKONGAS A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O. ❑ UNLEADED 4 GASAIOL ib PREMIUM E] 7 METHANOL ❑ 2 PETROLEUM ❑ Ba EMPTY 1 PRODUCT ❑ UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 16 UNKNOWN ❑ 2 WASTE V2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(AL1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK( ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 (NUM ❑ S 100% METHANOL COMPATIBLE W/FRP 5 CONCRETE MATERIAL ❑ (Primary Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 OXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑LL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F--] 5 CATHODIC PROTECTION ❑ 91 NONE I0-5 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A UU OWN 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 B 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 OW A U W OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 31 ERS ML99 OTHER MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE EV95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYMR) 2.E8 TIMATED OUANTITYOF 3.WAS TANK FILLED WITH YES EDNO❑ SUB STANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# ILITY TANK# STATE I.D.# 1T S p iqla) PERMIT NUMBER PERMIT APPROVED BY/OATE IT EXPIRATION DATE FORM S (9-90) THIS FORM MIDST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00MS-114 w - ✓