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STATE OF CALIFORNIA r��"V d`Or STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B � ` . . COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S�ocY��7M I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN / A. OWNER'S TANK I.D.# B. MANUFACTURED BY: U(C C. DATE INSTALLED(MO/OAY/YEAR) ��' D. TANK CAPACITY IN GALLONS: do U.TANK C NTS IFA-11SMARKED.COMPLETE ITEMC. 1 MOTOR VEHICLE FUEL ❑ d OIL e. C. ❑ 1aREGULAR UN EA ED 3 DIESEL ❑ e AVIATIONGAS A. ❑ 2 PETROLEUM ❑ N EMPTY PRODUCT ❑ ib PREMIUM A GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E::] 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.S.ANOC.AND ALLTHAT APPLIES IN BOXOANDIF A. TYPE OF ❑ 1,JDCXIBUE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Ea�,' BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 95 UNKNOWN 99 OTHER KYD LM ING F73 EPDXY LINING A PHENOLIC LINING C.INTERIOR F-15 GLASS LINING LINING 8 UNLINED ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MET14ANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP { FIBERGLASS REINFORCED-PLASTIC...- PROTECTION [:] 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ W 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 SUC A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U tlfidbi W AW 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 ♦ FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ IApERORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ l AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? VES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NgME DATE (PRINTED•3WNATIREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# F3-F COUNTY# JURISOICTKJN# FACILITY# �TANK�# �-7-�TIE I C M 10 F-T-T-1 I I I / s �J PERMIT NUMBER PERMIT APPROVED BY/OATE 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. FOg901