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- STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD - UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B � . . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT - 5 CHANGE OF INFORMATION q 7 PERMANENT = L E ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �I a TANK R OVA DBAOR FACILITY NAMEWHERE TANK IS INSTALLED:/oZr � V I. TANK DESCRIPTbN COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNERS TANK 1, D, B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY)YEAR) D, TANK CAPACITY IN GALLONS: O O ILTANKCONTENTS IFAA IS MARKED, COMPLETE REM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1aUNlEA EO �{REGULAR 3 DIESEL ❑ 6 AVIATION GAS A 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM LJ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM. D. BELOW) 0. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. S : III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B. AND C. AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF . F-11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 0 OTHER I� 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC B. TANK /,u�`• MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 lark METHANOL COMPATIBLE W/FRP (PrimaryTAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES _ NO_ D. CORROSION - [-] 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VI RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 ,` B. CONSTRUCTION . A U 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/ COATING A U 8 100%. METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U W OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MOLAR INTERSTITIAL ❑ N OTHER TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWNONO THER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MOIDAYNR) 2. ESTIMAD OUANTITY OF 3. WAS TANK FILLED WITH SUB STANTECEREMAINING GALLONS INERT MATERIAL YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT j APPLICANTS NAME DATE (PRINTEO831GNATUREI /1�3 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # ACILTTY # TANK # STATE LD .# Lal Cl PERMITNUMBER PERMIT APPROVED BY/DA PERMIT EXPIRATION DATE ' THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. /LI FILE THIS FORM WITHWCAL AGENCY IMPLEMENTING THE UNDERGROUND S]GE TANK REGULATIONS FORM 8 (12-91) FORD SAb