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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EAC�" TANK SYSTEM. j MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PEAMANENY CLO IT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REM VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN A. OWNER'S TANK L D. S B. MANUFACTURED BY: la REGULAR C• ElUNLEADED 6 AVIATION GAS C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: lb PREMIUM m 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL II. TANK CYNTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL E]4 OIL B. la REGULAR C• ElUNLEADED 6 AVIATION GAS F--]2 PETROLEUM ❑ 80 EMPTY i PRODUCT❑ lb PREMIUM m 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. III: III. TANK CONSTRUCTION MARK ONE ITEM ONI Y IN ROXFS A R ANTI C ANTI Al I THAT APPI IFS IN ROY n A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Eff 2,PNGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER 1 SINGLE WALL EZ'i BARE STEEL F--]2 STAINLESS STEEL F73 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 9 GALVANIZED STEEL ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING❑ 3 XY LINING r74 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN E] 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D. CORROSION F71 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATIM CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IFAPPLICARLF A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A A,99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH <2-A5 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 S L COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U UNKNOWN A U 99 OTHER D. LEAK ECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [:]2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL gg OTHER ❑ MONITORING V. LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING FY 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# F;-F,-4FY 1010 1[=LLLM le Iola 16]�U PERMIT NUMBER PERM IT APPROVEDBY/DATE PERMIT EXPIRATION DATE v�� f I / i FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. (/� FOR00346-144