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ou. e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i s ° UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B W�� / y4 COMPLETE A SEPARATE FORM FOR EACH T SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE [:] a TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.# 8. MANUFACTURED BY: U C. DATE INSTALLED(MO/DAY/YEAR) V K D. TANK CAPACITY IN GALLONS: O ILTANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A i REGULAR 3 DIESEL MOTOR VEHICLE FUEL ❑ 6 OIL B. C. UNLEADED ❑ 8 AVIATION 6A4 E] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b1a PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE �2 LEADED 99 OTHER (DESCRIBE BJ ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ff 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANIQ ❑ 92 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS C:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDEMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN E] 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ N 3 EPO LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED L—}AB/UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATINGL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 3 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TY E 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a 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 PROTECT ON A 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31N,IMSIRING RAL ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 MATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED Ol1ANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS I INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE ny� n Iar2TIEDa 91GN4TURE1 —V7 ^/ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# NT = 1001--wixTD 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. w9oax9-aa