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STATE OFCALIFORNIA �( '`"�• STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# 2 1 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) G D. TANK CAPACITY IN GALLONS:11.TANK 06NTENTS IFA-1 ISMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 6 OIL 8. C- I.REGAOED 3 DIESEL ❑ 6 AVIATIONGAS UNLE 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ 1b PREMIUM A GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 9D OTHER (DESCRIBE IN REM D. BELOW 0. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Sea4 L' {'L C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D ANDE A TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD WJ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PdmwyTuJI) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINE ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNO N ❑ 99 OTHER LINING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO Ulnj/ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION V91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EGUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUN 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 wAL A U DOUBLE WALL A U 3 LINE TRENCH A U 95 UNKNOWN A U 90 OTHER C. MATERIAL AND A 1U t BARES A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODK:PROTECTtON A U 95 UNKNOWN A U 90 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LE DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ AgNRORING ❑N OTHER V.TANK LEAK DETECTION W Blh ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ d AUTOMATIC TANK GAUGINGGROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHERS 2 VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MONAYIVR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES =1 NO LJ 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 IPRINTE9 A&G.ANR, / A`J LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I n 4--�i COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 39 = PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. n n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORME (12.91) 1r 6 IFTMS.96 v+