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"'g0 wCp STATE OF CALIFORNIA i STATE WATER RESOURCES CONTROL BOARD i ? UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM B COMPLETE A SEPARATE FORM FOR WH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE Q B TANK REMOVED 2!E FACILITY NAME WHERE TANK IS INSTALLED: C I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.x B. MANUFACTURED BY: 0-0 C. DATE INSTALLED(MCIDAYNEAR) / 0. TANK CAPACITY IN GALLONS: /o II.TANK5@WENTS FAA ISMARKED,COMPLETE ITEM C. REGUA"A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. taUNLEA ED 3 DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM d GASOHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADEDUNLEADE99 JO ERL(DESCPISE IN ITEM D. SELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.v: III. TANK CONSTR ION MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALL THAT APPLES IN BOX D AND A. TYPE OF rvi 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 WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001. 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 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP NRII FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT 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 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A 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 gr4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATNG A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNW40WN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATA:LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONIIORMG ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK INVENTORY RECONCILIATION F73 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ S GROUNDWATER MONITORING F-] 6 TANK TESTING EV7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED CLANTITY OF 3.WAS TANK FILLED WITH !!�� SUBSTANCE REMAINING GALLONS YES INERTMATERIAL? ❑ NO U THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICAN91MDATE PRIN LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY x TANK# V STATE I.D.# Z 3 z 1 I 1 Z PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 1 2 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. U1 FILE THIS FORM WITH" -LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST' 'GE TANK REGULATIONS FORM B (12-91) FOROM46 Ra