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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD '>, UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B `.� COMPLETE.A SEPARATE FORM FOR EACH TANK SYSTEM. I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT /❑ 6 TEMPORARY TANK CLOSURE EDB TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: — 5 A]r c�✓"7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a O B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) �� D. TANK CAPACITY IN GALLONS: ILTANK C NTS IF A-1 IS MARKED,COMPLETE REM C. A, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ IAUNLEADDERD DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ N EMPTYO PRODUCT 1PPREMIUM 4 IS L 7 METHANOL ❑ UNLEADED 6 JET FUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 05 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A1)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 D AND A TYPE OF ❑ 1 USLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 6 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 IW% METHANOL COMPATIBLE WTRP (PrimaryTank) ❑ 0 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 NYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C I TENOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN 09 OTHER LIN IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ATING ❑ 3 VINYL WRAP ED4 FIBERGLASS REINFORCED"PLASTIO PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U S 100% 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 ❑ MCNrron.G ❑W OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST U D(MO/DAY/YR) 2.ESTIMATED QUANTITY OF ^ 3.WAS TANK FILLED WITH YES NO 9Z. SUB STAN CE 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 IPPoNTED 8 SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION# FACILITY a TANK A {'}CC EAU T/ STATE LD.# ma 8 � I I I IO I PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT E)(P,IRATION ATE( } FORM B (7 911 THIS FORM MUST BE ACCOMPANIED BY APERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. _/,1� FORo6w