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• nt STATE OFCALIFORNA • °`��,,. co STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B :� s COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM o MARK ONLY ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ONE CLOSED ONSITE ❑ 6 TEMPORARY TANK CLOSURE a TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: f / I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.% B. MANUFACTURED BY: C. DATE INSTAL D(MO/DAYA'EAR) /1jJ� D. TANK CAPACITY IN GALLONS: II.TANK C TENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. i MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR �I 3 DIESEL 2 PETROLEUM UNLEADED =, ❑ 6 AVIATION GAS ❑ ❑ 80 EMPTY 1 PRODUCT ❑Jb PREMIUM LLLJJJ 4 GASAHOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE rt-�/ UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL LUCK JJ 2 LEADED ❑ 5 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.%: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,ANDC.ANDALLTHATAPPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 UMINUM 6 100% METHANOL COMPATIBLE WIFRP (Pflmtry Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 1yr95 UNKNOWN ❑ 99 OTHER C.1 F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑ FOXY LINING 4 PHENOLIC LINING LININGR ❑ 5 GLASS LINING ❑ 6 UNLINED 96 UNKNOWN ❑ 98 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES,_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 89 OTHER IV.PIPING INFORMATION CIRCLE A IFA13OVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER R. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U S U WN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COAT PROTECTION A U 9 GALVANIZED STEEL A U a 100% METHANOL COMPATIBLE W/FRP A U 10 CATHODIC PR OTECTION A U 9 KNO A U 99 OTHER D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAN DETECTOR O 2 LINETIGHTNESS TESTING 71NTEgSTITWL ❑ 99 OTHER V.TANK LEAK DETECTION MONITORING ❑ ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ gUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE L SED1 p0y ) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING G4LLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, APPLICANTS NAME IS TRUE AND CORRECT (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR COUNTY# JURISDICTION# FACILITY# TANK STATE LD.# I a m = g PERMIT NUMBER PERM IT APPPRO�VEDJB_Y_/DJATE L�.�1_ILQL(�. /� ERMI I EXPIRATION DATE _ FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. R I a, 9 / FOROOJOB R4