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• • eeso y" es W eot^ STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FORH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT N S 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED OIT MARK ONLY O ❑ 4 AMENDED PERMIT El TEMPORARY TANK CLOSURE ❑ 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 0. MANUFACTURED BY: �+ A. OWNER'S TANK I.D.# D TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOIDAYIYEAR) II.TANKCONTENTS IFA-115 MARKED,COMPLETE ITEM C. 1,REGULAR 3 DIESEL ❑ 6 AVIATION GAS L OTOfl VEHICLE FUEL ❑ 4 OIL B. C. ❑ UNLEADED 4 GASAHOL 7 METHANOL UM ETROLEUM ❑ 90 EMPTY ❑ 1 PRODUCT ❑ 1eUNL AIDED ❑ 5 JET FUEL HEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.#: OT MARKED, ENTER NAME OF SUBSTANCE STORED IIIF TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALLTHAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL ❑ 3. SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN 99 OTHER ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wi FIBERGLASS REINFORCED PLASTIC 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ B t00Y. METHANOL COMPATIBLE W�FRP L ❑ ❑ 99 OTHER k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING 5 GLASS LINING ❑ 6 UNLINED ❑ 85 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F—] 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVE GROUNDORUIFUNDERGROUND,BOTHIFAPPLICABLE 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 p U 2 DOUBLE WALL A U 3 LINED TRENCH A U 85 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 6 CONCRETE A U 7 STEE 95)UNKNOWN A U TING A 9910WTM% RETHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 95UNKNOW OWNMATIC TANK GAUGING O S�GORO EF WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES ❑ NO❑ 2.ESTISTANCE REMAINING GALLONS INERT MATERIAL? 1.ESTIMATED DATE LAST USED(MOIDAV/VR) SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY TH STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK u COUNTY it JURISDICTION p FACILITY# STATE I.D. I(/S PERMIT NUMBER PERMIT APPROVED BV/DATE 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 FILED FOR00MB RS