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STATE OF CAUFORNA / STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B > �e COMPLETE A SEPARATE FORM FOR EA TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EYS CHANGE OF INFORMATION 7 PERMANENTLY/L ONE REM ❑ 2 INTERIM PERMIT r-1 a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMO D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Qd r u /v I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# 77 S. MANUFACTURED BY: C. DATE INSTALLED(MODAY/YEAR)V D. TANK CAPACITY IN GALLONS: II.TANK G&TENTS IFA-IISMARKED.COMPLETE ITEM C. U 1/ laREGULAR n 3 DIESEL A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. U LEADED L�JI p �µpL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODl1CT REMIUM ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ % UNKNOWN ❑ 2 WASTE 2 Le 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. SELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ly 1 BARE STEEL ❑ 2 STAINLESS STEEL O 3 FIBERGLASS ❑ d STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNW40WN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNNG ❑ 3 OXY LINING ❑ a PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 V WRAP ❑ l FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMAT14 CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p UNKNOWN A U 90 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U < FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STE L W/COATING A U 8 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U UNKNOWN A U 99 OTHER D. LEAK DETECTION Q 1 ADToMATIC LINE LEAK DETECTOR Q 2 LINETIGHTNESSTESTING Q J HIAONRORND [3B9 OTHER V.TANK LEAK DETECTION T[:7] 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTRIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED IMOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLRINTEO K;AaNTS E DATE _ IGsIGNNAM,1TUNEl /� /✓�/ rl LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 6 v p7T If 10 10 10 1101 / PERMIT NUMB ER PMIT APPROVED BY/DATE PERMIT E%PIRATION DATE FORM 8 (9-9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.