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OUR STATE OF CALIFORNIAr `O>^ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "�� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM °""°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE ONSITE ONE REM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �--8 TANK REMOVED J DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -5 6 �' O I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.4 '7— B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYIYEAR) D. TANK CAPACITY IN GALLONS: Z oQil II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. V A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OILB. O. ❑ 1a REGU R ❑ 3 DIESEL ❑ e AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL JULZAeM ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE L2"2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4: III. TANK CONSTRUCT-1 MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALLTHAT APPLIES INBOX D AND A. TYPE OF UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LININGUNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%MINETTHANOL? YES_ NO— D.CORROSION 1 POLYETHYLENE WRAP ❑ 2 COAT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATIO CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND1 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 U 7 STEEL W/COATING A U 8 100% 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 ❑ 3 INTERSTITIAL 99 OTHEfl MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK F—] 2 INVENTORY RECONCILIATION [:] 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING E715 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING lQ" 'o'•- ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST D(M /D YNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES19 Z_ 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 (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY♦ TANK# QIL Lf STATE I.Dl [2�3 FT-F-1 U16:1 ell C 2 PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE 2 FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.