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• � Pt60 v„n. CO <br /> P w <br /> STATE OF CAUFORMA ' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE <br /> LDBA <br /> NLY � 1 NEW PERMIT 6 TEMPORARY TANK CLOSURE 0 TANK REMOVED <br /> EM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ ❑ <br /> FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> S. MANUFACTURED BY: �,K• <br /> A. OWNER'S TANK I.D.% T <br /> D. TANK CAPACITY IN GALLONS: <br /> C. DATE INSTALLED(MO/DAVIVEAR) <br /> II.TANKCONTENTS IFA-113MARKED,COMPLETE ITEMC. aREGULAR O 3 DIESEL ❑ 6 AVIATION GAS <br /> 0. ❑ UNLEADED ❑ 4 GASAHOL <br /> A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 1 PRODUCT lbPREMIUM <br /> ❑ 7 METHANOL <br /> O 2 PETROLEUM ❑ 90 EMPTY ❑ ❑ UNLEADED ❑ 5 JET FUEL <br /> 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> C.A.S.#: <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,ANDC,AND ALL THAT APPLIES IN BOXD <br /> ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> A. TYPE OF ❑ 99 OTHER <br /> SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANq <br /> ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W'FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ALUMINUM ❑ 0 100% METHANOL COMPATIBLE W/FRP <br /> MATERIAL ❑ <br /> (PflmeryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED <br /> ❑ 2 ALKYD LINING 3 PDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOfl ❑ 5 GLASS LINING ❑ 6 UNLINED 96 UNKNOWN ID go OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 1009:METHANOL? VES_ N <br /> D.CORROSION 95 U <br /> ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 yINKNOWN NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> ❑ 99 OTHER <br /> PROTECTION El CATHODIC PROTECTION ❑ 91 NONE <br /> MME32N!- <br /> FORMATION CIRCLEAIFABOVEGROUNDORUIFUNDERGROUND.BOTHIFAPPLICABLE <br /> PE A�1 SUCTION A U 2 PRESSURE p U 3 GRAVITY A U 99 OTHER <br /> TION A U 1 SINGLE EELWALA U <br /> 2 DOUBLE WALL A U 3 LINED TRENCH 5 UNKNOWN A U 99 OTHER <br /> ND p U t BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE WIFRP <br /> N 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER <br /> ON A U 9 GALVANIZED STEEL A U 9 INTERSTITIAL 99 OTHER <br /> 1 AUTOMAT IC LINE LEAK DETECTOR ❑ 2 LINETCHTNESS TESTING ❑ MONRORING ❑ y- <br /> D. LEAK DETECTION ❑ ._. <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING�UNKNOWC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH <br /> 2.ESTIMATED TV OF VES [-] NO❑ <br /> 1.ESTIMATED DATE LAST USED(MO/DAV/VR) SUBSTANCE REMAIREMAINING GALLONS INERT MATERIAL 7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF A4Y KNOWLEDDGEE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME <br /> (PRINTED 6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# TANK# <br /> STATE I.D.# a <br /> PERMIT NUMBER <br /> PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROMS-Ra <br />