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STATE OFCAUFORTAA STATE WATER RESOURCES CONTROL BOARD ; g UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B as .�7 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT °l4 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ITE ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT +6 TEMPORARY TANK CLOSURE Q 6 TANK RE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: c., ` I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF U MOWN A. OWNERS TANK 1.0.8 S.MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) a 0. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-I IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL B. C ❑ la REGUL R 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM EMPTY ❑ 1 PRODUCT ® Ib PREMIUM 4 GAE L ❑ 7 METHANOL 3 CHEMICAL.PRODUCT 95 UNKNOWN 2 WASTE UNLEADED 5 JOT FUEL ❑ ❑ � ® 2 LEADED j 99 OTHER (OESCRtBE IN ITEM D.BELOW► 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX O AND E A. TYPE OF l 1 DIXLBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CIAO Wi FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 955 UNKNOWN ❑ 99 OTHER I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LIMING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING fUNING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL.PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A75 GRAVITY A U 99 OTHER B. CONSTRUCTION A u 1 SINGLE WALL u 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 C14LORCE MMA 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 TESTI G ❑ kbNtTOR� C:]N OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAOOZE MONrmRiNG ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ® go OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTITY OFI 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT NAMEOATSAP s tPnNM0 RSIGNaTUR4 LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# c , U STATE I.D.# 3y PI1�� 6 131�=t PERMITNUMBER I PERMIT APPROVEDBYIDATE (PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH—'�LOCAL AGENCY IMPLEMENTING THE UNDERGROUND S"'SAGE TANK REGULATIONS FORM B (12.91) �a � FOROM48-R6