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IIAIEOFCAIIFOANIA STATE WATER RESOURCES CONTROL BOARD \ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B (/ y W mea' >b COMPLETE A SEPARATE FORM FOR MARK ONLY R E CH TAN c ONE ITEM ❑ I NEW PERMIT K SYSTEM. ❑ 2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT - 'o""� ❑ 4 AMENDED PERMIT 5 CHANGE OF INFORMATION DBA CR FACILITY NAME W ❑ 9 TEMPORARY TANK CL 7 PERMANENTLY CLOSED ON ITE HERE TANK IS INSTALLED: CLOSURE 8 TANK REMOVED I. TANK DESCRIPTION A. OWNER'S TANK I.D.# COMPLETE ALL ITEMS-. SPECIFY IF UNKNOWN - // �O C. DATE INSTALLED(MODgyryEgq) C B. MANUFACTURED By: II.TANK COD.NTS FA-715MARKED,CpMpLE�ITEM C. TANK CAPACITY IN GALLONS: A. 1 MOTOR VEHICLE FUEL 4 OIL B ❑ 2 PETROLEUM C. a REGULAR 3 DIESEL ❑ SO EMPTY ❑ 3 CHEMICAL PRODUCT PRODUCT UNLEADED ❑ 6 AVIATION GAS ❑ 1b PREMIUM 4 GASAHOL E] 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF(A.7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 98 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND E C.A.S-#: A. TYPE OF ❑ 1 f10UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM fI–I– ' SI E WALL El96 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 4 100%STEEMETHANOL Wi FIBERGLASSCOMPAUIEW/REINFORCED PLASTIC (Primary Te9k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ETHANOL COMPATIBLE W/FgP ❑ C.INTERIOR1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 LINING O 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN F-� 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_yyWJJggqN��yO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING 1:1 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION [:] 91 NONE VVV��III—aaa]]]Q5 UNIWOWN O 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENTINSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A, SYSTEMTYPE 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 I 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 8 100% METHANOL COMPATIBLE WIFRP 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 ❑ MONIrOBING ❑99 OTHER V.TANK LEAK DETECTION I 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMOMTORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 1/n_11 ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO� SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME ✓/� IPRINTEG 6 SIGNAWR LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBE COUNTY# JURISDICTION# ,-FACILITY# TANK# 3-LV STATE I.D.#/ 7i ERMI NUMBERC/ PERMIT APPROVED BYIDATE PIRATION DATE �A THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ✓ FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (12-91) /01:f:— FORMS R6 I