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STATE OFCALIFORMA °g ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B w�� e as.r . 1. o id+ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ��"'°""�� MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED qONSITEONE 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.i B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) U45 ig D. TANK CAPACITY IN GALLONS: IWO II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. X 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1-UN EA ED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL '❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUC ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER N E OF SUBSTANCE STORED C.A.S.III: III. TANK CONSTRUCTION MA ONE ITEM ONLY IN BOXES A.9,AND C.ANDALLTHAT APPLIES IN BOXD AND A. TYPE OF ❑ 1 DOUBLE WALLF-13 SINGLE WALL WITH EXTERIOR LINER El95 UNKNOWN SYSTEM F-12 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ B9 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTenk) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑\1METHANOL D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WIT ? YES_ NO- D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COAG ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE F7 95 UNKNOWN ❑ 99 OTHER E.SPILL ANDOVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNPERGROUND,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 U 95 UNKNOWN A U S9 OTHER C. MATERIAL AND A U 1 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECT N A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION OI AUTOMATIC LINE LEAK DETECTOR O2 LINE TIGHT ESS TESTING 3 INTERSTITIAL MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION aESTDATE K ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORI G ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING G ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E S ( OAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING !E/ GALLONS INERT MATERIAL 7 YES NO O E BEST OF MY EDGE, IS TRUE AND C APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �S7 47 COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN LED. 10-a /-9aFI,�