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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s'y UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B �4nuw COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE r 8 TANK REMOVED e DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /�, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# p O o 3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) JD. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1eUNLEADED ULAR 3 DIESEL ❑ g AVIATIONGAS ❑ 2 PETROLEUM ❑ 90 EMPTY Z PRODUCT O ib PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALLTHAT APPLETS IN BOX D AND A. TYPE OF I❑ / DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM L}7 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S IDD% METHANOL COMPATIBLE W/FRP (PHmmyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LININ C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑�3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE LZ95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT IINSSTTTAALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE P/ A A. SYSTEM TYPE A U 1 SUCTION p 19 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A62 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 fW 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 B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTK)N ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 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 YES NO U .� SUBSTANCE REMAINING GALLONS INERTMATERIAL7 ❑ ❑ THIS FORM HAS EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTf06gWNAT 0 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION 9 FACILITY# TANK# STATE LD.# ® 3 I I I I I I I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE b THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. REGULATIONS FILE THIS FORM WITH T"E LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST^nAGE TANK FORM (12-91) FOROm BRS