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soup e e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B W m� y: . , o COMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a 3 (oy q /9 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# d B. MANUFACTURED BY: ce/<- C. DATE INSTALLED(MO/DAY/YEAR) G(- D. TANK CAPACITY IN GALLONS: II.TANK CO S IFA-11SMARKED,COMPLETE ITEM C. I�I A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ laIREGULAR 3 DIESEL E:] 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT O 1bP IUM LJ 4 GASAHOL E:] 7 METHANOL LEADED ❑ 5 JET FUEL F-] 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 1--] 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 U"LL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 GUE WALL ❑. 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimuyT#Rk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 EUUNNIIIC40WN ❑ 99 OTHER ❑ 1 RUSBER LINED ❑ 2 ALKYD LINING E::] 3 LINING D 4 PHENOLIC LINING C.INTERIOR ❑ 5 BASS LINING E] 9 UNLINED L—d UNKNOWN © 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F--] 5 CATHODIC PROTECTION L::] 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPINGINFORMATIO A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE i SU TION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WA L A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A E STE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMI A U 6 CONCRETE A U 7 STEEL W/COATING A U S 10D% 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 ❑ 3INTERTITIAL ❑ OTHER MONORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING [:] 7 INTERSTITIAL MONITORING ❑ 91 NONE 96 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO� SUB STANCEREMAINING GALLONS I INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNRTUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 13R] = g p / PERMIT NUMBER PER MIT APPROVED BY/DATE P IT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORO6M9