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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i4 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE F0 CH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT a 3 RENEWAL PERMIT CHANGE OF INFORMATION Q 7 PERMANENTLY SITE ONE REM ❑ 2 INTERIM PERMIT A AMENDED PERMIT 8 TEMPORARY TANK CLOSURE Q 8 TANK REMOVED OBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MCIOAYIYEAR) D. TANK CAPACITY IN GALLONS: if.TANK CONTENTS IFA-11SMARKED.COMPLETEITEMC. to REGULARI 3 OESEL A. � 1 MOTOR VEHICLE FUEL � a OIL A C. � UNLEADED ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ W EMPTY EL 1 PRODUCT ❑ 10 PREMIUM A SIL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED O.A A a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLES IN BOX D AND A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 9s UNKNOWN SYSTEM � B. TANK 2 SINGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER 1 BARE STEEL C:] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD WI FIBERGLASS REINFORCED PLASTI: MATERIAL. 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (Pdmvy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LWNG ❑ 3 EPDXY UNNG ❑ A PHENOLIC LINING C.INTERIOR ❑ LINING 5 GLASS UN9W ❑ 5 UNLINED fV95 UNKNOWN ❑ 99 OTHER IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ I POLYETWLENE WRAP ❑ 2 COATING ❑�T 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC '7�L PROTECTION ❑ 5 CATHCOICPROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) �Y OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) T IV.PIPING INFORMATION CIRCLE A IFABOVE OUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION ACUL'_o SINGLE WALL 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 STANLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUM9NM A U 8 CONCRETE A U 7 ST&n Wl COATING A U 8 100X METHANOL COMPATISLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION j UNKNOWN A U 9a OTHER D. LEAK DETECTION 1 AUTOMATIC LIKE LEAK DETECTOR ❑ 2 LINE TIGHTNESSTESTING ❑ MONITORING ❑ N OTHER V.TANK LEAK DETECIII�TTiOTTTN ❑ ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNA) 12.ESTIMATED QUANTITY OF I 1 WAS TANK FLIED WITH YES a NO= SUBSTANCE REMAINING 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 DATE IPRINTE9 s SKaiATURq LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION s FACILITY• TANK s STATE I.DA Mg I O PERMITNUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FlLED,,,,.��,,,,��pppp q, FILE THIS FORM WITH TMc LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STT`OAGE TANK REGULATIONS /j( FORM B (1291) - Fommws