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STATE OF CALIFOFNA STATE WATER RESOURCES i 'i i+'Y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR E5H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ® 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D.# all B. MANUFACTURED BY: C ❑ 18 REGULAR ❑ C. DATE INSTALLED (MO/DAY/YEAR) ❑ 2 PETROLEUM D. TANK CAPACITY IN GALLONS: ❑ 1 P DUCT ❑ ib PREMIUM 11. TANK CONTENTS IFA -1 IS MARKED- COMPLPTEITEMa- A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C ❑ 18 REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 P DUCT ❑ ib PREMIUM ❑ 2 STAINLESS STEEL 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT E:]95 UNKNOWN WASTE UNLEADED ❑ 2 LEADED ❑ 5 JET FUEL (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED D LINING ❑ 3 EPDXY LINING C. A. S. # III. TANK CONSTRUMION MARK ONE ITEM ONLY IN ROxES A R_ AND C_ ANn Al I TWAT APPI IGc IN RnY n A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT AULTEDTANK) ❑ 99 OTHER B. TANK ❑ i BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001E METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE ❑ 1 RUBBER LINEDVS D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO A U D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF: MOVE GROUND OR U IF:UNMRrRAUNn RnTW ICAPPI IreR1 C A. SYSTEM TYPE A U i SUCTIONU PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 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 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 OTECTION A U<!95 UyKp(04V A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR Z2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL NTELR TI ❑ 99 OTHER GL V. TANK LEAK DETECTION E❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION E:]3 VAPOR MONITORING ❑ 4 TOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE as 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 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# l I 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. FOR0M4B-R4