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STATE DFCALIFOFUAA STATE WATER RESOURCtS CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B F COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM °'�•�-�'' MARK ONLY ❑ I NEW PERMIT ❑ 3 REuEWAL PERMIT S CHANGE OF INFORMATION r( T,�RMANENTL CL S"� ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE {fin/g TANK REM FD DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I e 1. TANK DESCRIPTION co E ;ACC ri ms_ sPEc:FY IF uNxxowN A.OWNERS TANK L D.a B. MANUFACTURED BY: f a C. DATE INSTALLED N00AWYEAR !r 0. TANK CAPACITY W GALL 4S: II.TANK C ENTS IFA.IISIIAPIKED.COMPLETErrEMC. A. 1 MOTOR VEHICLE FUEL ❑ 4 all B. C• 1iUNLEACEO 3 OIEs /2 PETROLEUM ❑ ea EMPTY 1 PRODUCT 1L PREMIUM L E7::]UNLEADED S JET FUEL3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DES:O:a i 0. IF(A.1)IS NOT MARKSD, ENTER NAME of SUBSTANCE STORED CAS.4 } 111. TANK CONSTRUCTION MARK ONE ITEM ONLY INBOXES A,B.AND C.AND ALL THAT APPLIES INBOX D A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM �S94GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TAN)q ❑ 99 OTHEFI B. TANK ❑ I BASE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBEAGLASS REINFORCED PLASTIC � 3 MATERIAL ❑ s CONCRETE ❑ e POLYVINYL CHLORICE ❑ 7 UMIMJM ❑ B 100Y. ME HANDL COMPATIBLE W1FRP (Primary Tarr&) ❑ 9 BRONZE ❑ IO GALVANIZED STEEL 95 UN140IOWN ❑ 99 OTHER ❑ I AUBBER LINED ❑ 2 ALKYD LINING ❑ 3 XY L24WG ❑ A PHENOLIC LINING C.INTERIOR ❑ s Gt�►ss LINING a a1NLINEo 95 UNNI LINING ❑ ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH IC0%METHANOL 7 YES_ NO,_ 0.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASM CDS CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CISCLE A IF ABOVE GROUND OR U IFUNCESG,ROU NO-80THIFAPPLICABLE } A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 90 OTHER R B. CONSTRUCTION A U 1 SINGLE wALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNxNpwN A U 99 OTHER ' C. MATERIAL AND A U I 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 a CONCRETE A U T STEEL WICOATIFK3 A U e 100x METHANOL COMPATIBLE W1FRP I PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A V 96 UNI4VOWN A U 99 OTHER ! 0. LFAK DETECTION ❑ I AUTCMAr.0 LINE LEAK OET-rCTOA ❑ 2 LINE TIGHTNESS TESTING ❑ uL 99 OTHER 11CMRORRIO ❑ F V.TANK LEAK DETECTION I' r VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ ❑ 3 VAPOR MpNfTORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WA—.,Ft eR MCNITCRSNG O ❑ e TANK TESTING [37 WTEASTITIAL MONTTQRING CD91 NONE Cl 95 UNpmwN ❑ 99 OTHER I A TANK CLOSURE INFORMATION I 1.ESTIMATED DATE LAST USED(MWAYNM 2.ESTIMATED CUANTTTY OP 3.WAS TANK FILED WrTH SUBSTANCE REMAINING GALLONS INERT 11ATHRIAL 1 YES ❑ NO❑ { THIS FORM NAS BEEN COMPLETED UNCER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT p APPUCANrs NAME 3 IPt7uftEo a ereluTuaq �DAT;e� i LOCAL AGENCY USE ONLY THE STATE LD.NUMBERS COMPOSED OF THE FOUR NUMBERS BELOW 1 i L[ COUNTY 2 JURISOICTICN 2 FACILITY s STATE �.D.� ��.V TANK x ) ` ® CZE n PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT E rAAT10N DATE FORM B (9.901 THS FORM MUST BE ACCOMPANIED aY A PERMCT APPLICATION•FORM A.UNLESS A CURRENT FORoau&:LI