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j STATE OF CALIFORNIA om STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 0 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ON SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 B TANK REMOVED F0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a 410 s AU, I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# ,3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR HICLE FUEL ❑ 4 OIL S. C. ❑ 14 R LEUL ED RI � 3 DIESEL 6 AVIATION GAS 0 2 PETROLEU ❑ 80 EMPTY ❑ 1 PRODUCT PREMIUM 4 GASANOL 7 METHANOL ❑ ❑ ❑ ❑ 3 CHEMICAL PRO T ❑ 95 UNKNOWN 0 2 WASTE 2 UNLEADED 5 JETFUEL LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, EN NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION ARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT AWLES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WA L ❑ 3 SINGLE WALL WITH EXTERIOR NER F-] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT AULTED TANK) F—] 99 OTHER B. TANK ❑ i BARE STEEL 0 2 STAINLESS STEEL 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 U INED ❑ 95 UNKNOWN 99 OTHER LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% THA L? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATIN ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION ❑ 81 NON ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED( AR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE G OUND OR U IF UNDER OUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A 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 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 TEEL W/COATING A U 8 100%, METHANOL COMPAT113LE W/FRP PROTECTION A U 9 GALVANI DSTEEL A U 10 CATHODICPROTECTKXJ p D 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTO M IC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION 0 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 0 6 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 0 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE 0 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS IN MATERIAL? YES 0 NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (POINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN AGE TANK REGULATIONS -0. FORMB 112-911 • � FOR99MB-Rb