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• 0 STATEOFCAUFORMA �^�s °°s STATE WATER RESOURCES CONTROL BOARD iA 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �° ns COMPLETE A SEPARATE FORM FOR EA TANK SYSTEM. °�l.�U�Y.� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5KS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED QuSnE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A O B. MANUFACTURED SY: C. DATE INSTALLED(MO'DAYIYEAR) D. TANK CAPACITY IN GALLONS: II.TANKC ENTS IFA-11S MARKED.COMPLETE ITEM C. REGULAR 3 DIESEL A to 1 MOTOR VEHICLE FUEL ❑ 6 OIL B. C. UNLEAOED ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM a GASAHOL 7 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.x: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ x SECONDARY CONTAINMENT (VAULTED TANKI ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE7 UMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PNmaryTank) ❑ 9 BRONZE ❑ 10 GALVAN12 STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3,2PDXY LINING ❑ d PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Lff95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A a 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A([)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 A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A/%w UNKNOWN A U 99�9.-5�OT*K D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING:. ❑ IIAONRORING L_I 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING E 5 OFiOUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTH VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERTMATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (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.# ® J / I/�D�21 I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION GATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITIV.LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST-�:GE TANK REGULATIONS FORMS (12-91) D�/ 5� / FORUM/8