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• fEe�u,y po STATE OF CALIFORNIA • r n 9 STATE WATER RESOURCES CONTROL BOARD t mom' o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. [DBA ARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a TANK REMOVED UQ OR FACILITY NAME WHERE TANK IS INSTALLED: brn kA I. TANK DESCRIPTION COMPLETE ALL ITEMS SPECIFY IF UNKNOWN B. MANUFACTURED BY: A. OWNER'S TANK LD.it C. GATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 6 ILTANKCONTENTS IFA-ISMARKED,COMPLETE IT C. Lc) ,D MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 18UN UNLEADED REGULAR 3 DIESEL ❑ 6 AVIATION GAS A. 1 PRODUCT 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM 80 UNLEADE CHEMCALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADEDD ❑ 99JOTHERL(DESCRIBE IN REM D. BELOW) S NOT 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 ❑ 1 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK6 POLYVINYL CHLORIDE ED ALUMINUM E] B 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE ❑ (P(mary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER _. LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE M A U 6 CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP CORROSION A U S ALUMINU 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 DETEC'gR ❑ 2 LINE TIGHTNESS TESTING 71 MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED OUANTITV OF 3.WAS TANK FILLED WITH 1.ESTIMATED DATUS O/ AY/YR) SUBSTANCE REMAINING GALLONS INERT MATERIAL YES NO Tf1L THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �FAC�ILITY# TANK# STATE I.D.# m uJ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B IS 90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOIIOtt1684/