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STATE OF CALIFORNIA lft�4 "mow c STATE WATER RESOURCES CONTROL BOARD' UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B "�� o s COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �""`""'� MARK ONLY ❑ 1 NEW PERMIT D RENEWAL PERMIT O 5 CHANGE OF INFORMATION O PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT F--j 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: pi Q I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. OWNERS TANK LD.# r B. MANUFACTURED BY: C. DATE INSTALLED(MO/OAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK COUTENTS IFA-11SMARKED.COMPLETE ITEM C. 1-11 to REGULAR 3 DIESEL A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• UNLEADED Q a AVIATIONGAS ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ❑ lb PREMIUM 4 GASAHOL 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT a 95 UNKNOWN 0 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(Al)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S./: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.13,AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ^❑ II DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERXJR LINER 95 UNKNOWN SYSTEM I� 2 SI LE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER B. TANK 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM F7 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 0 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER F-1AL 1 RUBBER LINED 2 D LINING ❑ 3 EPDXY LINING O 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING tL a/UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 CO TING O 3 VINYL WRAP. ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 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 U OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 5 CONCRETE A U 7 ST L W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANRED STEEL A U 10 CATHODC PROTECT ION UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3INTERSTITIAL ❑ 99 OTHER MONRORmG V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 1[:]l 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING Q 5 GROUND WATER MONITORING S TANK TESTING ❑ 7 INTERSTITIALMONITOflINO 1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE TUS MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH WEE SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ ;07 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (MAIM0 a SIGNATIREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FA TANK STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORMS(9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FFILE 7-11_—A / FORu`0x9/^J/M 1w V