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• • .esu:.,. STATE OF CAUFORMA � i� STATE WATER RESOURCES CONTROL BOARD w�� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B y: COMPLETE A SEPARATE FORM FOR E TANK SYSTEM �.o.°"r,. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED v �!7 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C) / SY 11 o r � , I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# K # B. MANUFACTURED BY: uM C. DATE INSTALLED(MO/DAY/YEAR) O D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF AI IS MARKED,COM ETEITEMC. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL S. C. ❑ 1a REGULAR 3 DIESEL ❑ 6 pyIATION GAS Um 4 GASAHOL METHANOL 2 PETROLEUM ❑ El 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Ej❑ 2UFA EDD ❑ 99J0THERLEMPTY (DESCRI0IN7ITEM D. BELOW) D. IF(A.1)IS N0T MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM EV2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIB RGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL B. TANK CHLORIDE ❑ 7 ALUMINUM E::] B 1004: METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ FOXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 96 UNNOWN ❑ W OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTHIF LICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVIN 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 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 STEELW/COATING A U B 100% METHANOL C0MPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINETIGHTNESSTESTING ❑ O MONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANKTESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY It JURISDICTION It FACILITY# TANK# STATE I.D.# 2 I � i fig.a] PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE yv FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROW&R4 • �� • "2