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STATE OF CALIFORNIA -r.•°°"`�*�^ STATE WATER RESOURCES CONTROL BOARD ;`� , ,�� `;r UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ; - COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. - E;;T ❑ 1 NEW PERMIT c'"�-�1•❑ ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 7 PERMANENTLY CLOSED ❑ 6 TEMPORARY TANK CLOSUREY NAME WHERE TANK IS INSTALLED: a TANK REMOVED y. I. TANK DESCRIPTION COMPLETE RLL ITEMS-- SPECIFY IF UNKNOWry A. OWNER'S TANK C. DATE INSTALLED(MO/DAYA'EAR) •wi! B. MANUFACTURED BV: D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. (JCl A. �Kl1 MOTOR VEHICLE FUEL ❑ q OIL B ❑ 2 PETROLEUM 80 EMPTY C. ❑ 1aUNLEADEO 3 DIESEL �-1 PRODUCT g 4 GASAHOL ❑ 6 AVIATIONGAS 1b PREMIUM ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8 AND C,AND ALL THAT APPLIES IN BOX D AND E CA.S.#: A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM �2 SINGLE WALL ❑ ❑ 95 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK li�1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ MATERIAL ED CONCRETE ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM (PrimaryTank) ❑ g BRONZE ❑ B 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ q PHENOLIC LINING LINING ❑ 5 GLASS LINING 15�K6 UNLINED IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ 95 UNKNOWN ❑ 99 OTHER VES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 3 VINYL ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL E IV. PIPING INFORMAIION CIRCLE AIFASOVEGROUNDORUIFUNDERGROUND.BOTH IFAPPCBETIONEQUIPMENT INSTALLED YEAR) A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 89 OTHER C. MATERIAL AND A 1 BARE STEEL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)p U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE PROTECTION A U 9 GALVANIZED STEEL A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION. ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 UNETIGHTNESS TESTING 3 5 A V.TANK LEAK DETECTION MONROgING 99 OTHER �. ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ gg OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMAT DAT. STT USE OD Y/YR) 2.ESTIMATED QUANT ITYY OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH TI-I'S FORM HAS BEEN COMPLETED UNDER PENALTY OFGALLONS INERT MATERIAL? YES PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT CORRNO E APPLICANTS NAME CT (RRINTEG4 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �P — ' STATE I.D.# COUNTY# JURISDICTION# FACI� _ 71 m �m TANK# LPEMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS l FOR00145R6