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ti STATE OF CALIFORNIA f STATE WATER RESOURCES CONTROL BOARD i i c� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ",10 //r °4 rn pnNJ 0 ,/((yf/ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT XI 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT `'��❑E 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED j DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.k B. MANUFACTURED BY:15 C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLCNS: •/ V II.TA'lNKKCONTENTS IFA-1 IS MARKED,COMPLETEITEMC. A lyl 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR F73 DIESEL ❑ 6 AVIATIONGAS �/ UNLEADED ❑ 4 GASAHOL 2 PETROLEUM 90 EMPTY 1 PRODUCT 1b PREMIUM F-17 METHANOL Ix F73 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E::] 2 UNLEADED L EADED ❑ 99'OTHER (DESCRIBE IN ITEM D. BELOWf D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.v: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ICN 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 0 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK E71 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100°/. METHANOL COMPATIBLE W1FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 0 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN El OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP '$jl`+4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) C, 3 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 99 OTiIER B. CONSTRUCTION A U 1 SINGLE WALL A(D2 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 G, FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING A U 9 100 METHANOL COMPATIBLE W1FRP 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 LINE TIGHTNESSTESTING ❑ 3 MOLAR TITIA ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING [7 5 GROUND WATER MONITORING ❑ 6 TANK TESTING X7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VL TANK CLOSURE INFORMATION 1.ESTIMATED XXST USED(MO1DAYNR) 2.ESTIMATED CUANTITY OF 3.WAS TANK FILLED WITH YESNO [ SUBSTANCE REMAINING GALLONS INERT MATERIAL? E::] THIS F M 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 OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE 04 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, ) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) 0 0 �fFOR0634R-R6 N. ) —rr 1'�