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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a� 9 ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EA5tjTANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION 7 PERMANENTLY CLOS SITE ONE ITEM ❑ 2 INTERIM PERMIT L::] 4 AMENDED PERMIT P141 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �(' jezt I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN L A. OWNER'S TANK I.D.N ul - • B. MANUFACTURED BY: C. DATE INSTALLS (MO/DAY/YE ) D. TANK CAPACITY IN GALLONS: l II.TANK C TENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. I- 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• a REGULAR G ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 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.o III. TANK CONSTRUqe0N MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF Pr 1 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNO SYSTEM 172 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 O R B. TANK F-] 1 BARE STEEL ❑ 2 STAINLESS STEEL E] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED n 2 YD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING C.INTERIOR ❑ 5 GLASS LINING �v�/ UNLINED ❑ 95 UNKNOWN E] 99 OTHER - - IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE O 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING 8 1001% METHANOL COMPATIBLE WlFRP PROTECTION A U GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER _ - - D. LEAK DETECTION Evi AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 TERSTITIAL MON ORING ❑ 99 OTHER V.TANK LEAK DETECTION -� 1 VISUAL CHECK ❑ INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER 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 SUBSTANCE REMAIN QUANTITO GALLONS 3.WAS TAN FILLEDMATERWIAL TH YES ❑ NOINERI- THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) ✓ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW G I OUNT # JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER ISERM IT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS F RM MUST BE AtCOMPANIED 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 l FORM B (12-91) FOR00346-R6