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STATE OF CALIFORNIA �P ..rte STATE WATER RESOURCES CONTROL BOARD s` , 90 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B C4 ,R COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMO Eqb DBA OR FACILITY NAME WHERE TANK IS INSTALLED: j> I. TANK DESCRIPTION COMPLETE ALL ITEMS--SPECIFY IFUWNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: �+ C. DATE INSTALLED(MO/DAY/YEAR) ►- D. TANK CAPACITY IN GALLONS: �© 00 II.TAN ONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1dUNLEAD D ❑REGULAR 3 DIESEL ❑ 6 AVIATION GAS A 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ib PREMIUM ❑ 4 GAS OL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT 0 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. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL F--14 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER E-11 BARE STEEL 0 2 STAINLESS STEEL � 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 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 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING , cavor 6 UNLINED ❑ 95 UNKNOWN E] 99 OTHER LINING ////"��"' IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUNO,BOTH IFAPPLICA13LE A. SYSTEM TYPE A U 1 SUCTION IJ 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION IIC 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 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 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 INTERSTITIAL 99 OTHER MONITORING E:l V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK2 INVENTORY RECONCILIATION F-13 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING FIOT B 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 OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERIi0CRY,AVN THE fqST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME . • ATE �.. (PRINTED a SIGNATURE) �- /,-„�,,. +-` ►'� �fi� rr a LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Y` COUNTY# JURISDICTION# FACILITY# TANK# l.. STATE I.DA ❑❑ 2 A I fift-N PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMB-R4 a