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• STATE OFCALIFORNIA • qua.. P n STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B o fOPPf COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITF MARK ONLY 0 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ , ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: t / a 4 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY:A. OWNER'S TANK 1.0. 2 Vvl MM D. TANK CAPACITY IN GALLONS: �Vv C. DATE INSTALLED(MOIDAY/YEAR) II.TANKCONfff NTS IFA-11SMARKED.COMPLETE ITEM C. 1:3111 !1 3 DIESEL ❑ 6 AVIATION GAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ UNLEADED 4 GASAHOL A. 1 PRODUCT 1b PREMIUM ❑ 7 METHANOL 2 PETROLEUM ❑ BD EMPTY UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPROOUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.%: E 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 ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIq ❑ 99 OTHER ❑ 2 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP AL ❑ �9S UNKNOWN ❑ 99 OTHER wk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED [: 5 DFKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ — ❑ 1 POLVE VLENE WRAP ❑ 2 COATING E] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 95 UNKNOWN 99 OTHER PROTECTION CATHODIC PROTECTION ❑ 91 NONE ❑ IV.PIPING INFORMATION CIRCLEAIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEMTYPE ALA PRESSURE A U 3 GRAVITY A U 99 OTHERB. CONSTRUCTION AWALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN p U 99 OTHERC. MATERIAL AND AEEL A U 2 STAINLESS STEEL A U 3 POL1'VINVL CHLORIDE(PVC)A U 4 FIBERGLASS PIPEOORROSION UM p U 6 CONCRETE A U 7 STEEL W/COATING A U 9 1009: METHANOL:COMPATIBLE WIFRP10 CATHODIC PR OTECTION UNKNOWN A U 99 OTHERPROTECTION I D STEEL A U 3 INTERSTITIAL gg OTHERD. LEAK DETECTIONTIC LINE LEAKDETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ V.TANK LEAK DETECTION 7EANKSUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING TESTING TERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH Yes No 2.ESTIMTANCEATED REMAINIUANTITYNG OF GALLONS INERT MATERIAL? ❑ ❑ 1.ESTIMATED DATE LAST USED(MOIDAVIVR) SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TE APPLICANT'S NAME (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® z 7 2 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT E%PIRATION DATE �� FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 0 B-114