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• STATE OFCAUFORNA '�esw•..a cc STATE WATER RESOURCES CONTROL BOARD • ;� -.� tQ / UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B COMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM `"•�^^'' MARK ONLY ❑ 1 NEW PERMIT t] 3 RENEWAL PERMIT CHANGE OF INFORMATION (:jyPERMANENTLY CLOSE 7E ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURELZ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.8 �^ S. MANUFACTUREDEIN M C. DATE INSTALLED(MC/OAY/Y'EAR) D. TANK CAPACITYGALLONS: [I.TANK C EMS IFA-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. G r[ElbPqEIMIUMI ULAR e 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 90 EMPTY 1 PRODUCT 4 GASAHOL ❑ 7 METHANOL ❑ 7 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE D UNLEADEI a 5 JET FUEL ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) O. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A B,ANDC.ANDALL THATAPPLIES INBOX0 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ f0 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INLININGR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 98 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 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 S. 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 8 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP 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 TESTING3INTERSTITIAL ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITYOF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IPNINTEO A SIGNATOREI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NNU7�MMBBBE�RRSS{BBE�-LOO�W-�/�� COUNTYR JURISDICTION FACT`—=`--`--L"'-:7 7 TANK STATE I.D.# � � � PERMIT NUMBER �( ,�� PERMIT APPROVED BYIDATE PERMIT EXPIRATION ATE _ e/ FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM k HAS BEEN FILED. FOR06}13R1 �\