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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B ?o , 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 ❑ S TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILTTY NAME WHERE TANK IS INSTALLED: U I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK L D.6 B. MANUFACTURED BY: C. DATE INSTALLED(MO(DAY/YEAR) / D. TANK CAPACITY N GALLONS: /6p UOD if.TANK CONTENTS IFA-1 ISMARKED.COMPLETERWC. 0. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. {{{{ F ❑ 1A R GLEADED 8 3 DIESEL 4 DASAHOL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODLICT tbUR FADED ❑ 5 JET FUEL ❑ 7METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D.BELlriV) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCT ON MARK ONE ITEM ONLY IN BOXES0.B.ANO C,AND ALL THAT APPLIES IN BOX 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM gg OTHER SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 85 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED n 3-ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LININGI^J�WEIB UNLINED ❑ 95 UNKNOWN CD 99 OTHER LINING IS LINING MATERIAL COMPATIBLE 100% METHANOL? YES_ NO— F-1 O_ D.CORROSION ❑ t POLYETHYLENE WRAP F-12 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] S CATHODIC PROTECTION [:] 91 NONE ❑OS UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(lo PRESSURE GRAVITY A U 99 OTHER S. 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 CHLORIDE(PVC) FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELWI COATING A U 8 IOD% 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 TESTING MONITORWG ❑99 OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES Flo SUBSTANCE REMAINING GALLONS INERTMATERIAL? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPaxreO a wcxATYREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 8 JURISDICTION 8 FACILITY 8 TANK 8 STATE I.D.# 3 p �*a, ;zL PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (&901 THIS FORM MIDST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. / FORam/6RIj