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STATE OF CALIFORNIA cO . <br />STATE WATER RESOURCES CONTROL BOARD W �, <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY ❑ 1 NEW PERMIT ❑ <br />3 RENEWAL PERMIT <br />❑ 5 CHANGE OF INFORMATION <br />❑ 7 PERMANENTLY CLOSED P94ft <br />ONE REM ❑ 2 INTERIM PERMIT CK <br />4 EN D P RMIT <br />,, ❑ 6 TEMPORARY TANK CLOSURE <br />❑ 8 TANK REMOVED <br />1 PRODUCT <br />n <br />1b PREMIUM <br />UNLEADED <br />(14-/ <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />a Ul°)t sylfln <br />��b <br />❑ <br />2 LEADED <br />❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br />❑ 9 BRONZE <br />L 1 ANK Ut,GHIN I IUN COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN <br />A. OWNER'S TANK 1.0.4 _ <br />B. MANUFACTURED BY: t= C <br />C. DATE INSTALLED (MO/DAYNEAR) I <br />D. TANK CAPACITY IN GALLONS: <br />ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. <br />A A 1 MOTOR VEHICLE FUEL <br />❑ 4 OIL <br />B. <br />C. <br />"REGULAR <br />UNLEADED <br />3 DIESEL ❑ 6 AVIATION GAS <br />❑ 2 PETROLEUM <br />F-180 EMPTY <br />1 PRODUCT <br />❑ <br />1b PREMIUM <br />UNLEADED <br />4 GASAHOL ❑ 7 METHANOL <br />❑ 5 JET FUEL <br />❑ 3 CHEMICAL PRODUCT <br />❑ 95 UNKNOWN <br />❑ 2 WASTE <br />❑ <br />2 LEADED <br />❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />C. A. S. #: <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D AND E <br />A. TYPE OF <br />1 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 95 UNKNOWN <br />SYSTEM <br />❑ 2 SINGLE WALL <br />❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) <br />❑ 99 OTHER <br />A U <br />❑ 1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />[y 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 100% METHANOL COMPATIBLE W/FRP <br />(PrimaryTank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />A U <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOP <br />❑ 5 GLASS LINING <br />� 6 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />LINING <br />D. LEAK DETECTION <br />Yl <br />AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 <br />MONITORING ❑ 99 OTHER <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES �NO _ <br />D. CORROSION <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUNO, BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A(P2 <br />PRESSURE A U <br />3 GRAVITY <br />A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A@2 <br />DOUBLE WALL A U <br />3 LINED TRENCH <br />A U 95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />A U <br />1 BARE STEEL <br />A U <br />2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE (PVC) AQ 4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />6 CONCRETE A U <br />7 STEEL W/ COATING <br />A U 8 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PROTECTION <br />A U 95 UNKNOWN <br />of <br />A U 99 OTHER <br />D. LEAK DETECTION <br />Yl <br />AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 <br />MONITORING ❑ 99 OTHER <br />V. TANK LEAK DETECTION <br />❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br />6 TANK TESTING d7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN O 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATED DATE LAST USED MO/DAYNR) <br />2. ESTIMATED QUANTITY OF <br />3. WAS TANK FILLED WITH <br />NO <br />S ❑ ❑ <br />SUBSTANCE REMAINING GALLONS <br />INERT MATERIAL ? <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME <br />(PRINTED 8 SIGNATURE) h �� <br />� j •� I <br />� <br />DATE <br />�/� / <br />` � r <br />� � � <br />LOCAL AGENCY USE ONEY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY # TANK # <br />STATE I.D.# ❑ O <br />PERMIT NUMBER <br />FORM B (12-91) <br />PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN F <br />FILE THIS FORM WITH &CAL AGENCY IMPLEMENTING THE UNDERGROUND STJOE TANK REGULATIONS <br />