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r 1 ' STATE OFCALIFORNIA .• � o STATE WATER RESOURCES CONTROL BOARD w w �p UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B B� , :: a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY F��NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ' INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.i _ B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) // - 17- D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA.11SMARKEO,OOMPLETE ITEM C. R A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B C ❑ UNLEADED IUM L-J 4 DGASAHOL2 PETROLEUM ❑ 7 METHANOL IESEL 6 AVIATION AS ❑ 3 CHEMICALPRODUCT O 90 EMPTY El 1 PRODUCT 1b PUNLEADED ❑❑ 5 JETFUEL 2 WASTE 2 LEADED 9B OTHER 85 UNKNOWN HER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOXES A,13,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ;,OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PdmaryTok) ❑ 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 Fee UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES_ NO— D.CORROSION ❑ / POLYETHYLENE WRAP ❑ 2 COATING ❑ 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) f4l OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A FABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPLICA13LE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A6)2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARESTEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE OW U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE Wff PROTECTION A U 9 LVANIZEO STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING99 OTHER e V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMA D ST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 31GNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# �r ^TANK# STATE I.D.# - - o TANK NUMBER PERMIT APPROVED BY/DATE 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 I)NOERGROUNO STORAGE TANK REGULATIONS FORM 8 (12-91) y0"-' � ( '`../ II�/ Jq-txe R3R0W4&R6