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'�5aua es STATE OF CAUFORMA r s STATE WATER RESOURCES CONTROL BOARD 3 ` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B CaLfvpN NSF COMPLETE A SEPARATE FORM FOR 50CH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONE ITEM 1712 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: tj I. TANK DESCRIPTION COMPLETE ALL ITEMS•- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O. ! B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYlYEAR) D. TANK CAPACITY IN GALLONS: ILTANKC, TENTS IFA-1 IS MARKED.COMPLETE ITEM C. {� �-1 1aUNLEADED u a DIESEL ❑ S AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 4 GASAHOL 2 PETROLEUM 80 EMPTY i PRODUCT ❑ 1 UNLEADEDREM UM ❑ 5 JET FUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 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.11 III. TANK CONSTRU ION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D ❑ 1 UBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM ❑ 2 SI LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 1 BARE TEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 140% METHANOL COMPATIBLEWJFRP MATERIAL ❑ 5 CONCR TE (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LI D ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN 99 OTHER LINING IS IS LINING MATERIAL CO PATIBLE WITH 100% METHANOL? YES— NO— E] O_❑ 1 POLYETHYLENE AP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION [:] 5 CATHODIC PROTEC ON 91 NONE 95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IF k6OVE 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 B. 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 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 WICOATING A U 8 1003 METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETE TOR ❑ 2 LINE TIGHTNESS TESTING ❑ MdNITORI GL ❑�`� OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATI ❑ 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING [--] 5 GROUND WATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.EST MA ED E LAST USED(MOIDAYIYR) 2.ESTIMATEb QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANT'S NAME (PRINTED 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.# m PERMIT B PER APPROV D YIDATE PERMITEXPIRA IeATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, FORD03413-144