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• <br /> STATE OF CALIFORNIA <br /> jl STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B 4 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ <br /> ONE I3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 7 PERMANENTLY CLOSED ON <br /> ❑ ❑ 6 TEMPORARY TANK CLOSURE 9 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A 410 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.x Z <br /> B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) <br /> D. TANK CAPACITY IN GALLONS: <br /> ILTANKCONTENTS FA-11S MARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B 1a REGULAR <br /> ❑ 2 PETROLEUM 60 EMPTY G ❑ UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS <br /> 1 PRODUCT ❑ 1b PREMIUM d GASAHOI <br /> ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 9B OTHER (DESCRIBE IN ITEM D. BELOW) <br /> C.A.S.%: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,ANDALL THAT APPLIES IN BOXD AND <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER <br /> SYSTEM ❑ 95 UNKNOWN <br /> I� 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT IVAULTEDTANK) ❑ 99 OTHER <br /> B. TANK �i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS <br /> ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 9 IDD% METHANOL COMPATIBLEWIFRP <br /> ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING <br /> C.INTERIOR ❑ 3 EPDXY LINING ❑ q PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING >M<6 UNLINED <br /> ❑ 95 UNKNOWN ❑ 9g OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING <br /> ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE <br /> ❑ 95 UNKNOWN ❑ gg OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) <br /> OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> ffLEAK <br /> TYPE !Au <br /> 1 SUCTION A U 2 PRESSURE <br /> A U 3 GRAVITY p U 99 OTHER <br /> UCTION 1 SINGLE WALL A U 2 DOUBLE WALL <br /> A U 3 LINED TRENCH p U 95 UNKNOWN p U 99 OTHER <br /> L AND 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> SION 5 ALUMINUM A U 6 CONCRETE <br /> TION GALVANIZED STEEL A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FqP <br /> A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> TECTION AUTOMATIC LINE LEAK DETECTOR 2LINE TIGHTNESS TESTING <br /> 3 MONRORING 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE <br /> ❑ 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMAT DAT AST USE D Y/YR) 2.ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING 3.WAS TANK FILLED WITH <br /> GALLONS INERTMATERIpL? YES ❑ NO <br /> TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO�THEBESOF MV KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS <br /> COUNTY# JURISDICTION FACILITY# <br /> STATE I.D.# m TAN <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE <br /> PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORME (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • ����� FOgOD11B-q5 <br />