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STATE OF CALIFORNIA �� •F' I'e+;., STATE WATER RESOURCES CONTROL BOARD i F.-! '�•� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B � >✓ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY LI 1 NEW PERMIT (—''. 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Iu�PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED D DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 'tc.+ — I. TANK DESCRIPTION COMPLETE ALL ITEI:S- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.I B. MANUFACTURED BY: C. DATE INSTALLED(MODAYHEAR) awl" D. TANK CAPACITY IN GALLONS: / ILTANKCONTENTS IF1ISMARKED.COM PL: IT EM C. SSS I_I 1 'ACTOR VEHICLE FUEL ❑i < C r'–• to REGULAR 3 DIESEL A. - C. 6 AVIA-,CN'GAS UNLEADED 2 PETROLEUM =_'JPTY ✓T PRODUCT ❑ 1EPREMIUTA A GASAHOL 7 METHA\CL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE L'CLEADED ❑ 5 JET FUEL ✓7-LEADED U 99 OTHER (DESCRIBE IN 17EM D. SELCYP D. IF(A,;)IS NOT MARKED. ENTER NAVE OF SUBSTANCE STORED C.A.S.c: III. TANK CONSTRUCTION MASK ONE ITEM ONLY IN BOXES A.B.ANC C,AND ALL THAT APPLIES IN BOX D ANDE A. TYPE OF ❑ 1 USLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 22 SINGLE WALL 6 SECONDARY CONTAINMENT (VAULTEDTANK) I❑ 99 OTHER S. TANK (❑k/ 1 SAFE STEEL 2 STAINLESS STEEL r73 FIBERGLASS L:14 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC _ MATERIAL ❑ 5 CONCRETE 6 POLYVINYL ::HLCRIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W:FRP (PrimaryTack) ❑ 9 BRONZE !0 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR n LINING 5 GLASS LINING _je--5—UNLINED = 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE W T H !0094 M.ETHAN'OL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOD'ICPROT'cCTION 1�91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INS-?,!EO(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFA=-CVEGRD'JNCOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A ! SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(Z1 S;NGLE WALL A U 2 DOUBLE WAIL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WJCCATI,NG A U 8 100-A METHANOL COMPAT;B;E 1'J.FSP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION I,_ 1 AUTOMATIC LINE LEAK S_T'c C70R I--� 2 LNETrHTNESSTESTYG51 "C "G 99 OTHER V.TANK LEAK DETECTION 'L_ 1 VISUAL CHECK IJ 2 INVENTORY RECCNC'LIATION 3 VADOZE MONITORING I_I a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MON'"CRING 6 TANK TESTING ❑ 7 IN'TERSTITIALMCN'-CRING �', 91 NONE !—, 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTItdA'ELnATE LAST USED QdO:CAY.Y"n) 2.ESTWATEDOUANTITY OF 3.WAS TANK FILLEDWITH !e SUBSTANCE REMAINING GALLONS INERTIVIATERIAL7 YES FJ' NO THIS FCRA1 HAS BEEN COMPLETED UNDER PENALTY OF PEP,JURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT '=PLICA\T 5 NAVE DATE I FR'il!E36SlGNATLRE)/ �') Ai _ • , A w LOCAL AGENCY USE ONLY•\)YT_HHEWSTAJTE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COL'NTYJURISDICTION# FACILITY TANK: � STATE I.D.# F, 3 3 a 9 oK PERMIT NUMBER PERMIT APPROVED BYJDATE I PERMIT EXPIR.Tv-nATF THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-0l) FOR I2 IIG