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w � STATEOFCAUFORIBA - STATE WATER RESOURCES CONTROL BOARD s 'O UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B "tl'a a° ry . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM c"��O""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CL N SITE ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV DBAOR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 1140. TANK CAPACITY IN GALLONS: /01 II.TANKCONTENTS FA-IISMARKEO,COMPI ITEMC. A. 1 MOTOR VEHICLE FUEL ❑ a OIL IL C. ❑ 1a REGULAR EO I P 3 DIESEL ❑ B AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY RODUCT lb PREMIUM A GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ S CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) O. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED G A.S.•: III. TANK CONSTRU ON MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF I DOUBLE WA' ❑ 2 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OT14ER S. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL 7 FIBERGLASS ❑ A STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WNRP (Pmmwy Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 7 EPDXY LINING ❑ l PHENOL%: LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER UNING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 VINYL WRAP s FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GR UND OR U,_ UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 2 GRAVITY A U 90 OTHER S. CONSTRUCTION A U 1 SINGLE WALL AU 2 DOUBLE WALL A U 2 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 0 POLYVINYL CHLORIDE(PVC)A 0 a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEELY#COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A V 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC UNE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ O AgNRORING ❑w OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK VENTORY RECONCILIATION ❑ 0 VADOZE MONITORING ❑ s AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OFI S WAS TANK FILLED WITH SUBSTANCE REMAINING 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 APPLICANTS NAME DATE )PRINTED f SIGNATURP LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# fo STATE I.D.9 Z�j ) a f =/ 0 PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE I THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH T' OCAL AGENCY IMPLEMENTING THE UNDERGROUND STO- TANK REGULATIONS u FORM 8 112-91) FORMBA6