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^ tb STATE OF CALIFORNIA i 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 RIS CHANGE OF INFORMATION ❑ 7 PERMANENTL O SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE ❑ 8 TANK RE VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 11 A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: e4 C. DATE INSTALLED(MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: ILTANKCO ENTS IFA-1 ISMARKEO,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C 1a REGULAR 3 DIESEL C 6 AVIATIONGAS F7 UNLEADED ASAHOL GA2 PETROLEUM ❑ 00 EMPTY �RODUCT ❑ 1bREMIUUNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPROOUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM M BELOW) D. IF(A.D ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.4: III. TANK CONSTRU ON MARK ONE ITEM ONLY IN BOXES A,S.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 2r 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ < SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL u 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmwyTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING C.INTERIOR � ❑ 5 GLASS LINING �UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER LINIS UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP Cj2�4_FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN E�] 99 OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 WE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U N OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 0d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORBIG ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITO � RING ❑ 6 TANK TESTING L�7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIOAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAMEGATE (PRINTED A SIGNANRID LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW eZ STATE LD.# COUNTY# JURISDICTION# FACILITY# TANK# °J 3 I i 1 / II PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION OATS THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 1 FILE THIS FORM WITH THS'OCAL AGENCY IMPLEMENTING THE UNDERGROUND STP'--STANK REGULATIONS FORM 8 (12-91) w9oauBRc