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04t STATE OF CALIFORNIA t' STATE WATER RESOURCES CONTROL BOARD s ° UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B "m� '° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. t��°"..,� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED x DBA OR FACILITY NAME WHERE TANK IS INSTALLED: p1 3 E. T/ F {J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS; ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B�( C. ❑ 14UNGEADED 3 DIESEL 6 AVIATIONGAS ❑ PETROLEUM ❑ 80 EMPTY �JCJ, 1 PRODUCT O 1b PREMIUM 4 GASAHOL O 7 METHANOL /— UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 86 UNKNOWN SYSTEM >t<2 8114GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK j BARE STEEL E] 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC r MATERIAL ❑ 5 CONCRETE F-1 e POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100x METHANOL COMPATIBLE W/FRP (PUmwyTARk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP IjO 2 COATING F-] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION !❑ 91 NONE O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE L SUCTION A U 2PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION ACU_) SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNW40WN A U 99 OTHER C. MATERIAL AND A("-'g BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PMA U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 IW% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ / AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING Nn 90 OTHER OYl V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING E::] 5 GROUND WATER MONITORING X6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATEDDATE LASTUSE11MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH _ SUBSTANCE REMAINING GALLONS INERT MATERIAL YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO 774E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME - DATE �7 =APPLICANTS i9 O L13 q I LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW O J COUNTY# JURISDICTION FACILITY It TANK# STATE I.DA ® = 1311101011 PERMITNUMBER PER MIT APPROVED BYIDATE PERMIT EXPIRATION DATE 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 FORM 8 (12.91) `�� -A I-q-5 FOROM&RII/