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• STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br /> • xe•°U" �° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT <br /> ONE ITEM ❑ ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ PERMANENTLY CLOSED ONSITE <br /> 6 TEMPORARY TANK CLOSURE <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z 6 TANK REMOVED 7)0 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# <br /> C. DATE INSTALLED(MO/DAV/YEAR) B. MANUFACTURED BY: <br /> D. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-11SMAgKED,COMPLETE ITEM C. <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B1 PRODUCT <br /> to REGULAR 3 DIESEL <br /> ❑ 2 PETROLEUM ❑ g0 EMPTY EJ6 AVIATION GAS <br /> ❑ ❑ Ib PREMIUM 4 GASAHOL <br /> ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL E] 7 METHANOL <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES&B.AND C,AND ALL THAT APPLIES IN BOX D CAS*- <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 ❑ 95 ry <br /> SECONDARY CONTAINMENT (VAULTED TANIQ El 99 <br /> 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL <br /> MATERIAL ❑ 5 CONCRETEe POLWINYL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> ❑ CHLORIDE ❑ 7 ALUMINUM <br /> (Primary Tank) ❑ 9 BRONZE ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN <br /> ❑ <br /> C.INTERIOR ❑ 1 RUBBER LINED 99 OTHER <br /> ❑ 2 ALKYD LINING <br /> LINING ❑ 5 GLASS LINING ❑ EPDXY LINING ❑ 4 PHENOLIC LINING <br /> ❑ e UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 <br /> VE9_ NO_ <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ El 3 VINYL ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> 91 NONE E]95 UNKNOWN <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH-'APPLICABLE❑ 99 OTHER <br /> A. SYSTEM TYPE A U 1 SUCTION <br /> A V 2 PRESSURE A U 3 GRAVITY <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINEA U 99 OTHER <br /> D TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL <br /> CORROSION A U 5 ALUMINUM A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> PROTECTION A U 5 GALVANIZED STEEL A U 6 CONCRETE A U 7 STEELW/COATING <br /> A U 10 CATHODIC PROTECTION A U B 100% METHANOL COMPATIBLE W/Fqp <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR A U 95 UNKNOWN p U 99 OTHER <br /> ❑ 2 LINE TIGHTNESS TESTING 3 ❑1NTE1151 TIAL ------ <br /> V.TANK LEAK DETECTION MONgORING 90 OTHER <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATE <br /> RMONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE <br /> ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1DATE LAST USED(MOI 2.ESTIMATED QUANTITY O <br /> F <br /> ­ FSUBSTANCE REMAININGGALLONS 3WqS TANK INERTMATERIAL7H YES ❑ NO❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> IRSINTED A SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# :­.-:­,_,,=� ::=:: <br /> STATE LD.# � NK# OPERMIT NUMBER I I''PERMIT L OE <br /> FORM B (9-91!) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORU,,B R4 <br />