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STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD � �? C�UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B _ v o COMPLETE A SEPARATE FORM FOR EAC K SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEMONS[TE ONE REM ❑ 2 INTERIM PERMIT [:] 4 AMENDED PERMIT F76 TEMPORARY TANK CLOSURE E:] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: N r v rti_o(w I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a / B. MANUFACTURED BY: /c- C. DATE INSTALLED(MOIDAY/YEAR) �� D. TANK CAPACITY N GALLONS: aooC II.TANK CO ENTS IFA-1 IS MARKED.COMPLETE REM C. RER A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. AUN FADED 3 DIESEL ❑ 6 AVIATION GAS a GASAHOL ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODl1CT ❑ taUN EAPREMIUM DED 5 JETFUEL El METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE N ITEM D. BELOW) D. IF(A7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.m: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERK)R LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL E] 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 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 ❑ 9 100% METHANOL COMPATIBLEWIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED KYD LINING F73 EPDXY LINING ❑ 4 PHENOLIC LINING SS C.INTERIOR ❑ 5 GLALINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSK)N ❑ 1 POLYETHYLENE WRAP n 2fAATING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCEIYPIASTIC PROTECTION ❑ 5 CATHODK:PROTECTK)N [:7/91 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 <SUCT2JQ A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 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 1RE 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 W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 ZE 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(MOAMV/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING _GALLONS INERT MATERIAL T YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJJPY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE WRNTED A SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 1r FACILITY 9 TANK♦ GF_OFS17 STATE I.D.# [ 3 7 PERMIT NUMBER _ PERMIT APPROVED BYIDATE PERMIT EXI TKNI DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY!.PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN%% 'V RO NM16 l� ti/