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• • a STATE OF CAUFORMASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 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 DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 1,4 Nbr2r c.�P�� ✓ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# U,A , B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) `/,K D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGUL ED ❑ 3 DIESEL ❑ g AVIATIONGAS A 2 PETROLEUM ❑ 80 TV ❑ 1 PflOWOT ❑ 16 PREMIUM ❑ 4 GASAHOL ❑ T METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 AL LIM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ XY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F-15 GLASS LINING F-] 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3VI L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 B. CONSTRUCTION A U i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3INTER51 ML ❑ 99 OTHER _ MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ OMATIC TANK GAUGING [-] 5 GROUND WATER MONITORING [_] 6 TANK TESTING F--] 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FAC ILI TANK# STATE I.D.# E:l I I Io PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (390) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. (/ RMOW48-R4