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� . • STATE OF CALIFORNIA ^ STATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM. MARK ONL 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT CLOSED ONE ITEM 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE 8 TANK RE VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: AY e I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN r % 9 -76 A. OWNERS TANK I.D.# 8. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYHEAR) D. TANK CAPACITY IN GALLO O il.TANK NTENTS IFA-IISMARKED.COMPLETE ITEM C. . A. 1 MOTOR VEHICLE FUEL ❑ 6 OIL B. C. E:] Ia REGUL E 3 DI ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY /IPRODUCT ❑ ib PREMIUM GASAHOL ❑ 7 METHANOL ❑ ❑3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED 5 JET FUEL 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOM D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALLTHAT APPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 6 STEELCLAD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLENFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ < PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 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 U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U s FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 7UL ❑ 99 OTHER MONRORNG V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 0 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATUBE) DATE ' /y� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.DA COUNTY# JURISDICTION# FACILITY# TANK# PERMIT NUMBER / PERMITAPPROVED BV/GATE PERM TEXPIRATION DATE FORMS (9-90) HIS FORM{MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 7