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STATE OFCALIFORMA STATE WATER RESOURCES CONTROL BOARD iV UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 7 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 131670 I. TANK DESCRIPTION COMPETE ALL ITEMS-SPECIFY IF UNKNOWN A OWNERS TANK I.D.# 3 8. MANUFACTURED BY: C. DATE INSTALLED(MOfDAWYEAR) D. TANK CAPACITY IN GALLONS: 15 II.TANKC S IFA-11S MARKED.COMPLETE ITEM C. SEG A 1 MOTOR VEHICLE FUEL ❑ s OIL B. C. t_7 UNLEADED e A DIESEL L a AVUTIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ lbUN EAPREMIUM DED 5 GASAHJETFUL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED g 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(Ai)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.m: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX O AND A TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ ♦ SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER B. TANK BARE STEEL ❑ 2 STAINLESS STEEL E] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 6 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE WIFRP P%mmyTa* ❑ 9 BRONZE ❑ 10 GALVAN2ED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 9B OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO- D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ ♦ FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE �VNOGOWN ❑ 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 ej PRESSURE A U 3 GRAVITY A U 98 OTHER B. CONSTRUCTSINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 85 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 A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEE W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER D. LEAK DETECTIONAUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING LJMORRORNG E9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 NVEN7DRY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ANK TESTING ❑ 7 WTERSTRIALMONRORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES [-] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANTS NAME (PLANTED A SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# i'?Cfba/�3 STATE I.D.# ® � 6 6 a PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FRED. > � /7