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�zOUnCF3 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �f nJ 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT [�( 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE ITEM a 2 INTERIM PERMIT O 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE E] 8 TANK REMOVED Q I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �--11E O I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL 2 PETROLEUM a 80 EMPTY 3 CHEMICAL PRODUCT a 95 UNKNOWN B. 1 PRODUCT 2 WASTE C �1a REGULAR a 3 DIESEL 6 AVIATION GAS UNLEADED 4 GASAHOL 1b PREMIUM 7 METHANOL UNLEADED ❑ 5 JET FUEL E:] 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOWi D IF (A.1) IS NOT MARKED ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B, AND C,AND ALL THAT APPLIES INBOX DAND E /N�1/�GLOn` �� jF/cD%/y K• A. TYPE OF ❑ 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM rg 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC 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 UNLINED F795 UNKNOWN 99 OTHER LINING EX6 IS LINING MATERIAL COMPATIBLE ITH 100% METHANOL? YES _ NO— D. CORROSION ❑ 1 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 EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND. BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION AfE)2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 0 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A(V4 FIBERGLASS PIPE 7 STEEL W/ COATING A U 8 1009/ METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION[::]1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 ❑ MOTERSTITIAL NITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING F-] 5 GROUND WATER MONITORIN( 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER5 f VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED IMO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES a NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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.#3 o rl �i�EYe 3 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348 1 4