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STATE OF CALIFORNIA ��= STATE WATER RESOURCES CONTROL BOARD .m� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B _ ° • ,.ory, . (/ COMPLETE A SEPARATE FORM FOR EA ANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /❑ a TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6f\-- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A.OWNERS TANK I.D.a S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-I ISMARKED.COMPI,0flTFMC. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. �"" _�f��''�'' C. ❑ 1aUN UNLEADED 3 DIESEL ❑ 8 AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ T ❑ 1bPREMIUMUNLEAO D 5 JEST FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED m/L C.A.S.m: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORM ❑ 7 INUM El 100% METHANOL COMPATIBLE W/FRP (Primary Tmk) ❑ 9 BRONZE ❑ 10 GALVANOED STEEL 96 UNXNOWN ❑ N OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNNG 03 BOXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR E:] 5 GLASS LINING ❑ 8 UNLINED ITL.r9/S UNKNOWN ❑ 99 OTHER LINING IS LNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D,CORROSION F-11 POLYETHYLENE WRAP E] 2 COATING ❑ 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTK)N ❑ 91 NONE UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGROUND BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 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 6 CONCRETE A U7 ST L W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LNETIGHTNESS TESTING ❑ 3 MDNR Ni"Ri"ALL ❑ B9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK G1IUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONTTORING ❑ 91 NONE 1,86UNKN0WN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 (PPoNTEDB$IGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW (/✓% COUNTY# JURISDICTION# FACILITY# TANK At STATE I.D.# JY = 100101001 PERMIT NUMBER PERMIT APPROVED BWDATE PERMIT EXPIRATION DATE FORM a (¢9% THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FDR0051&96