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STATE OF CALIFORNIA �O: STATE WATER RESOURCES CONTROL BOARD i�'. 2 UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B W�� a: ry, COMPLETE A SEPARATE FORM FOR EA ANK SYSTEM MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE N SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: !.n I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.a B. MANUFACTURED BY: uW C. DATE INSTALLED(MO/DAY)YEAR) D. TANK CAPACITY IN GALLONS: O U O ILTANKC ENTS IFA-11SMARKED,COMPLETE ITEMC. I MOTOR VEHICLE FUEL ❑ ♦ OIL B. C. ❑ UNLEADEDREGULAR3 DIESEL ❑ 8 AWATIONGAS A ❑ 2 PETROLEUM ❑ 9D EMPTY I PRODUCT ❑ Ib PREMIUM a GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMK:ALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.A: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 00118LE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ff Om- LE WALL ❑ a SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ERfi BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ ♦ STEEL CLAD WI FIBERGLASS REINFORCEOPUISTC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B t00% METHANOL COMPATIBLEW/FRP (PrimaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING XY LINING ❑ A PHENOLIC LINING C.INTERIOR F-15 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ N OTHER LINING 18 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE 5 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF A80VE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U S TK)N A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A USINGLE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A 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 GALVANM STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECT^R ❑ 2 LINE TIGHTNESS TESTING ❑ 1 MONITORING TERSTITIAL ❑ DD OTHER V.TANK LEAK DETECTIO ■ I VISUAL CHECKVE Y RECONCILIATION MONITORING❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE I.wxrlo a s1aN.IURtT LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 9 FACILITY 9 TANKS STATE LD.# 3 PERM.T NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (sW) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. IORIM&P1