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STATE OF CALIFORNIA `-� "�-"�"A s STATE WATER RESOURCES CONTROL BOARD i Wim, Il' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B xa "P I... D COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. o ". MARK ONLY �1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ S TANK gEMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: fVIL I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# 5— B. MANUFACTURED BY: } C. DATE INSTALLED(MOIDAWYEAR) 9 D. TANK CAPACITY IN GALLONS: 2 II.TANK CONTENTS IFA-11SMARKED,COMPLETEI EMC. A. ❑ 1 MOTOR VEHICLE FUEL OIL B. C. ❑ 1eUN EAO R 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE UNLEADED ❑ 5 JETFUEL ❑ ❑ �/ ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 4-"C s• C�, C.A.S.v: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,13.AND C.AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMSINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Pdnmq Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED E;a UNKNOWN ❑ 99 OTHER LINING 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 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,80TH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER B. CONSTRUCTION Aol SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 SAFE 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 U7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Aj�)m UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR Ew CI E TIGHTNESS TESTING ❑ 6 WTERSTITAL MONITORING 9B pTHER E:] V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 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 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 APPLICANTS NAME DATE (PRNTEO 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 3 2 Z -3 S S -s Ilo A� PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE /-75� 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 REGULATK)NS FORM B (12-91) FORO6N6-R6