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Fir_a .: <br />' P�gOV RCks C <br />r p <br />STATE OF CALIFORNIA :P <br />STATE WATER RESOURCES CONTROL BOARD W°o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY1 NEW PERMIT ❑ <br />~ W2 <br />3 RENEWAL PERMIT <br />F__]5 CHANGE OF INFORMATION <br />❑ 7 PERMANENTLY CLOSED ON SITE <br />ONE ITEM INTERIM PERMIT ❑ <br />4 AMENDED PERMIT <br />❑ 6 TEMPORARY TANK CLOSURE <br />❑ 8 TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />95 <br />❑ 2 WASTE <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I. D. # <br />B. <br />B. MANUFACTURED BY: <br />C. DATE INSTALLED (MO/DAYNEAR) <br />1,,1�" 4 PRODUCT <br />D. TANK CAPACITY IN GALLONS: <br />II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. <br />A m 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />C ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS <br />'F <br />u 2 PETROLEUM ❑ 80 EMPTY <br />1,,1�" 4 PRODUCT <br />NLEADED <br />lb PREMIUM1c <br />❑ 4 SINGLE WALL IN A VAULT <br />� <br />MDGRADEU UNLEADED ❑ JET T FUEL ❑ 8 M85HANOL <br />❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN <br />❑ 2 WASTE <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 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 OF1 <br />DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />E:]5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br />SYSTEM <br />2 SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />❑ 99 OTHER <br />B. TANK <br />❑ 1 BARE STEEL <br />❑ 2 STAINLESS STEEL <br />3 F113ERGLASS <br />4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />7 ALUMINUM <br />8 100% METHANOL COMPATIBLEW/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />C. INTERIOR <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />LINING OR <br />❑ 5 GLASS LINING <br />'4=e 6 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES NO— <br />nVINYL <br />D. EXTERIOR <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />WRAP <br />❑ 3 <br />N(4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION ❑ 91 NONE <br />❑ 95 UNKNOWN <br />lop__ <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL, etc. SPILL CONTAINME T INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />DROP TUBE YES NO STI PLATE YES '"1` NO DISPENSER CONTAINMENT YES NO <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />A U 1 SUCTION <br />A 2 PRESSURE A U <br />3 GRAVITY A U <br />4 FLEXIBLE PIPING A U 99 OTHER <br />B. CONSTRUCTION <br />A U 1 SINGLE WALL <br />ACV) L DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />A U 1 BARE STEEL <br />A U 2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE (PVC) A( U 6 4 FIBERGLASS PIPE <br />CORROSION <br />A U 5 ALUMINUM <br />A U 6 CONCRETE A U <br />7 STEEL W/ COATING <br />A U 8 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U 9 GALVANIZED STEEL <br />A U 10 CATHODIC PROTECTION <br />A U 95 UNKNOWN <br />A U 99 OTHER <br />D. LEAK DETECTION <br />[::] 1 MECHANICAL UNE LEAK <br />DETECTOR <br />2 UNE TIGHTNESS 0 3 CONTINUOUS INTERSTIT AL 4 ELECTRONIC LINE <br />TESTING MONITORING LEAK DETECTOR <br />5 AUTOMATIC PUMP 99 OTHER <br />SHUTDOWN <br />V. TANK LEAK DETECTION <br />❑1 VISUAL CHECK ❑ 2 RECONCILMANUAL IIATIONORY ❑ 3 MONITORING ❑ VADOZE4 GAUG NGAUTOMATIC TANK ❑ 5 MONITORINGGROUND WATER ❑ 6 TESTINGANNUAL <br />7 MONITOR CONTINUOUS ❑ 8 SIR ❑ 9 WEEK LY MAN ❑ UAL 10 MONTESTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER <br />VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) i IA <br />1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME DATE <br />(PRINTED 3 SIGNATURE) 3j(o0 <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY # TANK # <br />STATE I. Dl <br />PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED, FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br />SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TI&ERGROUND STORAGE TANK REGULATIONS <br />-95) <br />FORM B (6 <br />