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• ce oR <br /> STATE OFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i '0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE E <br /> ONE ITEM ❑ 2 INTERIM PERMIT [74 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE b� S TANK REMOVED /C <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CJ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.a B. MANUFACTURED BY: <br /> C. DATE INSTAL LED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 1 II l— <br /> II.TANKC TENTS IFA-11SMARKED,COMPLETE ITEM C. G�— <br /> tSREGULAR O 3 DIESEL <br /> A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ UNLEADED ❑ ❑ 9 AVIATIONGAS <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib PREMIUM 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADED ❑ 5 JET FUEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE � LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.>f <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ❑::] I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E:] 95 UNKNOWN <br /> SYSTEM IJQ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK1 BARE STEEL E::] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING �NLINED ❑ 95 KNOWN E:] 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO_ <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 OPWING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION1 NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPUCABLE <br /> A. SYSTEM TYPE A&)1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND AU 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A 5 ALUMINUM A U B CONCRETE A U 7 STEELW/COATING A U 9 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OSHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING Ej 3INTERSTITIAL gg OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> ❑ 1 ISUAL CHECK ❑ 2 INVENTORY RECONCILIATION [--] 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING n VGROUND WATER MONITORING <br /> 7 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST U5 ( O/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING ea GALLONS I INERTMATERIAL? YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME DATE <br /> (PRINTED 8 SIGNATURE) q� <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW 11r 1 <br /> COUNTY# JURISDICTION# �FACILITY# TANK# <br /> STATE I.DA Y 11 1 1 1 �1 Q <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> 414 <br /> FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOgOQ}fBg4 <br />