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STATE OF CALIFORNIA - ' STATE WATER RESOURCES CONTROL BOARD 3•,0� 8 UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY NEW ERMIT ❑ 3 RENEWAL PERMIT ❑ 5CHANGE OF INFORMATION ❑ 7 PERMANENT CLOSED C]AI.S1iE ONE ITEM 2 IN IM PERMIT ❑ A AMENDED PEAMIT _ [7� 6 TEMPORARI`-'TANK-0LO-$URE`�,.El TANK REM VEDQ / OBA OR FACILI HERE TANK IS INSTALLED: S L b I. TANK DESCRIPTION COMPLETE ALL ITEMS SPECIFY IF UNKNOWN FB- MANUFACTURED BY: A. OWNER'S TANK I.D.• b V V C. DATE INSTALLED(MOrDAYIYEARI V D. TANK CAPAC YIN GALLONS: ILTANKCONTENTS IF A4 IS MARKED.COMPLETE ITEM C. ❑ 9REGULAR 8 3 DIESEL ❑ 6 AVIATION GAS ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED 4 GASAHOL ❑ A. ❑ 1 PRODUCT ❑ tb PREMIUM 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY UNLEADED ❑ 5 JETFUEL ❑ 3 CHEWCALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.t)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK 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 A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ go OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 6 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 10014 METHANOL COMPATIBLE W/FRP MATERIAL ❑ )Primary 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 ❑ 96 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 95 PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM=ITFC TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONS1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINEO TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATE1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U s FIBERGLASS PIPECORS ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U B t00K METHANOL COMPATIBLE W/FRPPRO9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNIWOWN A U 9B OTHERLAL D. LEAKAUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TGHTNESS TESTING ❑ y WRrtORING ❑ 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 INTERSTITIALMOWTORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MO/DAY/YR) I 2.ESTIMATED SUBSTANCE REMAINING OIJANTI OFNING GALLONS INERT MATERIAL? YES [D NO❑ THIS FOATC RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ATE APPLICANTS NAME B )PRIMED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# D U 2 PERMIT NUMBER /_ PERMIT APPROVED BY/DATE )PERMIT EXPIRATION DATE FORMS 19-901 THIS FOAM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.