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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B Q COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, ' MARK ONLY ❑ 1 NEW PERMIT ONE ITEM ❑ 3 ONE PERMIT 5 CHANGE OF INFORMATION ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 T ❑ 7 PERMANENTLY CLOSED ONSITE EMPpggqy TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ❑ B TANK REMOVED O I. TANK DESCRIPTION COMPLETE ALL ITEMS–SPECIFY IF UNKNOWN A. OWNERS TANK I.D.A 0 B. MANUFACTURED BV: C. DATE INSTALLED(MOq)AyryEAq) ti'1 U h v\ D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 ISMARKED, ton s COMPLETEITEMC. O A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL ❑ 2 PETROLEUM BO EMPTY B ❑ 1 PRODUCT C ❑ lb PN EARED 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN �2 WgSTE UNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(q.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Wa �� C.A.5.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES M BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2T� ❑ 95 UNKNOWN IJ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 6 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7/ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pd-ryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING LINING ❑ ❑ 8 UNLINED UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E:] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 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 2 PRESSURE A IUT 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(�1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(g>5 UNKNOWN A U 99 OTHER DINTERSTITIAL . LEAK DETECTION ❑1 AUTOMATIC LINE LEAK DETECTOR 2 LINETIGHTNEBB TESTING ❑ 9 MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ROUND W TER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 10SO OTHER7,2, VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLER WITH YES NO SUBSTANCE REMAINING GALLONS IN MATERIAL? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PR)NTED A SI"ATJREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 8 JURISDICTION 8 FACILITY 8 TANK a 0 STATE I.D.# m 3 a � a PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE IV ID)17lj THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH T"-I.00AL AGENCY IMPLEMENTING THE UNDERGROUND STC"7ETANK REGULATIONS FOR09MeRb FORM B (12-91)