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STATE OF CALIFORNIA `001 STATE WATER RESOURCES CONTROL BOARD i +ate UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B o� u COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY W 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ,FL—= 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 313 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. B. MANUFACTURED BY: '� C. DATE INSTALLED(MQ(DAY/YEAR) (Ny� D. TANK CAPACITY IN GALLONS: II.TANKCO NTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8' C. Epor#UREGULAR NLEADED 3 DIESEL ❑ e AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY EpllePRODUCT ❑ ib PREMIUM 4 GASAHOL O 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE O 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 NE ITEM ONLY IN BOXES A,B.AND C,AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL E] 3 FIBERGLASS E 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) O 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED Nw ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING UNLINED ❑ 95 UNKNOWN 99 OTHER LINING ❑ IS LINING MATERIAL COMPATIBLE100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP O COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9 NONE ❑ 95 UNKNOWNO 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED AR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGRODORUIFUNDERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U APRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 BLE 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 TAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B C CRETE A U 7 STEEL W/COATING A U 8 100 METHANOL COMPATISLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 THODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 99 OTHER MONRORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION VADOZE 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 I.ESTI A D DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNATIREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT M R q PERMIT APPROVED.B /DATE qJ PERMIT EXP( NDAT FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEE / FOR(KNIBR5