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^'w... STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD A Wim, a UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B »: COMPLETE A SEPARATE FORM FORJVCH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT pf 5 CHANGE OF INFORMATION ❑ 7 PERMANE TLY CLOSED I ONE ITEM ❑ 2 INTERIM PERMIT 4 AMEN PER i 6 TEMPORARY TANK CLOSURE 9 TANK RE OVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: s I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK C ENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1e REGULAR 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. Q U DED 116 AVIATION GAS F--12 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b EMIUM 4 GASAHOL ❑ 7 METHANOL ,ANLFAOED 5 JET L F-13 CHEMICAL PRODUCT O 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 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,13.AND C.AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF F7/' ABLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Cy 2 NGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EP LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN E::] 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 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 95 UNKNOWN A U 99 OTHER - ` C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE ►\�V\ CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3IAINTERSTITIAL ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK F-12 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 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 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG9, IS TRUE AND COR T APPLICANTS NAME E (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW '1.y / COUNTY# JURISDICTION# � LD TANK# 38 y ESTATE 1.Dl 0 PERMITNUMBER PERMIT APPROVED BY ATE RM IT EXPIRATION DATE T FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRE A HAS . FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) FOIIOMB