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STATE OFCALIFORMA STATE WATER RESOURCES CONTROL BOARD T4 ¢ UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION IW7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACR.ITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 / B. MANUFACTURED BY: u,^ C. DATE INSTALLED(MOIDAYIYEAR) � D. TANK CAPACITY N GALLONS: J Opp II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. ��q A. F—] 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C LST UN EAGED 3 DIESEL ❑ 6 AVIATIONGAS F-1 2 PETROLEUM �a0 EMPTY � PRODUCT 1DPREMIUM A GASAHOL 7 METHANOL �❑,/UNLEADED ❑ S JETFUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE U 2 LEADED ❑ 99 OTHER (DESCRISE N ITEM D.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND A TYPE OF F❑ 11 DOUBLE WALL � 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM EVj'2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK l.J ;BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ { STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary TNN) ❑ B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ a PHENOLIC LINING C.IUNNIOR ❑ 5 GLASS LINING E�1-6 UNLINED ❑ 95 UNKNOWN E] 09 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ ♦ FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION Q'91 NONE ❑96 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(PEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A iWl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AQ1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A V 96 UNKNOWN A U 90 OTHER C. MATERIAL AND AnD I BARE STEEL 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 WI COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A O 95 UNKNOWN A U 1999 11 014ER •A_� D. LEAK DETECTION ❑ EE 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING W OTHER AO' V V.TAN5 LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ a AUTOMATIC TANK GAUGING ❑ 6 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST U ED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF /\ 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING 1/ 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 (PRATED A SIGNATURE) 1 ,�Q�� DATEi1JfX�D W �r T)I x-5-1? LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER 6 COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY A TANK# (0 STATE LD.# m kid-ED PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATIM-nITV Z 12 �{ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMS (12 91) FILE THIS FORM WITH THFI OCAL AGENCY IMPLEMENTING THE UNDERGROUND STOPACE TANK REGULATIONS Ig-,A3-y7APe F9RAMBRM