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STATE OF CALIFORNIA �,.✓ .�.• `'� STATE WATER RESOURCES CONTROL BOARD �� > UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �-`""""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ l AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED O9 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ["' � N , er v ti Jti 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a O S. MANUFACTURED BY: �LC� C. DATE INSTALLEO(MLVDAYATM) t e D. TANK CAPACITY IN GALLONS: 3-SZ7 II.TANKC ENTS IFA-1 ISMARKED.COMPLETE ITEM C. A. I MOTOR VEHICLE FUEL ❑ 4 OIL a. C. ❑ /a REGUUNLEARD 3 DIESEL ❑ 3 AVIATIONGAS F72 PETROLEUM E:] 4 GASAHOL BO EMPTY 1 PRODUCT ❑ IEP LEADED O 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E] 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALLTHAT APPLIES INBOX GANG 1 BLE WALL 3 SINGLE WALL WITH EXTERIOR LINER A. TYPE OF � / 011 ❑ ❑ es UNKNOWN SYSTEM L-V/2 LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 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 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCEO"PSsTK:- -- PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER `—_- E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED MAR) IV.PIPING INFORMATION CIRCLE A IFA80VEGROUNOOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 90 OTHER B. CONSTRUCTION A U 1 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 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 S CONCRETE A U 7 STEELVUOOATING A U B tOTH METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK F72 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 0 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED( Y/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED W RH YES (1 SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE(PRINTED■SKRU M LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION a FACILITY A TANK• roDTEt_ /fi STATE I.D.# FiT = EI]2 T� PERMITNUMBER PERMIT APPROVED SYIOATE �PERMITEXPIRATK)N DATE FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILEp�