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STATE OF CALIFORNIA V4111104 r•r Vp ' `°s, STATE WATER RESOURCES CONTROL BOARD t4 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B �`� �e `I ll COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `.`�`°�,. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SI ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# -5 B. MANUFACTURED BY: L/� C. DATE INSTALLED(MO/DAYA'EAR) D. TANK CAPACITY IN GALLONS: ✓ 5 O ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ❑ ❑ ❑ laREGED LAR 3 DIESEL ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. /� C. 6 AVIATION GAS ❑ 2 PETROLEUM ❑ SO EMPTY LLS/1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ ❑ 2 LEADED O 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 ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 LISLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK BARE STEEL F--] 2 STAINLESS STEEL [—] 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 6 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1004: METHANOL COMPATIBLE W/FRP (PdmmyTAOk) ❑ 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 UNLINED ❑ 95 UNKNOWN O 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 INVL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F] 5 CATHODIC PROTECTION F-191 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A.0 3 GRAVITY AQ 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U B5 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR L-12 LINE TIGHTNESS TESTING ❑ 3 MON70RING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ i 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 ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DAT LAST U O/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED YES ❑ NO❑ 3 SUB STANCE REMAINING GALLONS 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 SIDNATURE) 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 FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. `I � 3' FOB90164t5