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�Acoun < STATE OF CALIFORNIA ^< STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W�� P �4�sONM�A 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 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ g TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# O B. MANUFACTURED BY: G, C. DATE INSTALLED(MO/DAYIYEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 ISMARXEDy�.C�OMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL LJ 4 OIL B. C. ❑ 18UNLEADED REGULAR 3 DIESEL ❑ g AVIATIONGAS 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT 16 PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(AA)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.': III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOXD /? Er—F&'41 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM E)r2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK I>rl RARE STEEL F—] 2 STAINLESS STEEL F—] 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIALF-15 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primuy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER O 1 RUBBER LINED ❑ 2 ALKYD LINING O 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING O 5 GLASS LINING EWg UNLINED O 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? VES_ NO�C— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN E:] 99 OTHER 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 A&A GRAVITY A U W OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AU 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U g CONCRETE A U 7 S/T�EE—L�W/COATING A U B 100% METHANOL COMPATIBLE WIFRP , PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Com' UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 7 MONITORI G ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK F—] 2 INVENTORY RECONCILIATION F—] 3 VAPOR MONITORING Q 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK LOSUREINFORMATIO 1.ESTIMATED DATE LAST USED(MO/D N 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES L:] NO ❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRIMED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.DA M � I I I I Ir PERMITNUMBER PERMIT APPROVEDBY/DATE PERMIT EXPIRATION DATE FORM B (390) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM&RI