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STATEOFCALIFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B . . o COMPLETE A SEPARATE FORM FOR EA ANK SYSTEM. MARK ONLY 1 PERMIT ❑ 3 RENEWAL PERMIT ELKS CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT �❑ a TEMPORARY TANK CLOSURE E:] 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: sy 9 /'� 7 64 �O �AI I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.i 9. MANUFACTURED BY: / C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: f� IL TANK C ENTS IFA-t ISMARKED.COMPLETE ITEMC. 1aUNLEADED REGULAR3 DIESEL A. 1 MOTOR VEHICLE FUEL 6 OIL B. C. ❑ ❑ 6 AVIATOR GAS ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ ib PREMIUM 4 WSAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNIQ40WN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOm D. IF(A.t)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.i: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES AL S.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL CD3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 IOD% METHANOL COMPATIBLE W/FRP (PNmuy Tmk) ❑ B BRONZE ❑ 10 GALVANIZED STEEL 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 KYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING, C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 9D OTHER �,/,�/` LINING IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 21 91 NONE ❑26 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGR NEOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U2 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 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U t 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 S CONCRETE A U 7 STEELW COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 N 99 OTHER MONITORING ❑ V.TANK LEAK DETECTION / ❑ i VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUNDWATER MONITORING 9 TANK TESTING ❑ 7 INTERSTRLLLMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION t.ESTIMATED DATE LAST USED(MOfOAv/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 AAPPLICANTS NAME DATE PFINT SIGN.A,U , s �s LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 9 FACILITY i TANK 9 STATE I. r ALU a a PERMIT NUMBER PERMIT APP 'Y?' Y PERMIT EXPIRATION DATE FORM B(9-9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ��(� FOROf01BR1