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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ^c`,. ` UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B :� , a COMPLETE A SEPARATE FORM FOR EACH ANK SYSTEM. ..• �c MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT c•`•' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 5 CHANGE E INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /a 0 S I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D. C. DATE INSTALLED 8. MANUFACTURED BY: LJ/C MO'DAY/YEAR) t4 0-- D. TANK CAPACITY IN GALLONS: pod ntAN-, S IFA.IISMARKED.COMPLETEITEMC. VEHICLE FUEL ❑ 4 OIL B. C• ❑ 18UNLEA ED 3 DIESEL ❑ 8 AVIATION GAS EUM ❑ 80 EMPTY 1 PRODUCT 4GASAHOL ❑ 1eUNLEAIDED 5 JETFUEL ❑ 7METHANOL L PgOpUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADEDIn�jRKED, ENTER NAME OF SUBSTANCE STORED u OTHER (DESCRIBE IN ITEM D. BELOW) C. III. TANK CONSTRUCITIOgN CONSTRUCTIONMARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLES IN BOX D AND E A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ' SYSTEM 2 LE WALL ❑ 95 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrlmaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑ 2 D LWWG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING El8 UNLINED 5 GLASS LINING LINING ❑ 95 UNKNOWN ❑ 99 OTHER IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑VI WRAP 4 FIBERGLASS REINFORCED FUSTIC PROTECTION El CATHODIC PROTECTION E] 91 NONE UNKNOWN ❑ w OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE ORO ERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U A U 3 cflAvm A u 99 OTHER S. CONSTRUCTION A U ING A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNIGIOWN A U W OTHER C. MATERIAL AND A U IflESTEEL A U 2 STAINLESS STEEL A V 3 PoLYVINYL CHLORIDE(PVC)A U s FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE p U 7 STEEL W/COATINO PROTECTION A U 9 GALVANIZED STEEL A U 10 ONCRE E PROTECTION A U 8 100% METHANOL COMPATIBLE WIFRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTOflY gECONCILIATK)N ❑ 3 VADOZE MONITORING 4 ATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTNG ❑ 7 WTERSTRIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED( V/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES SUBSTANCE REMAINING a ❑ NO 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 IPD.IK+N %MFM DATE LOCAL AGENCY USE ONLY THE STATE 1.0.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 8 JURISDICTION 8 FACILITY 9 TANK Y STATE I.D.# /_(20) s D3 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.