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v� c� w. ea `/\/ Oi STATE OF CAUPJRNIA r• STATE WATER RESOURCES CONTROL BOARD wV.N a UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B "oN �i � C�tl�I�N,�. COMPLETE A SEPARATE FORM FOR E TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EYF5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORAARRY TANK CLOSURE O 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: h I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: f-671 LCDWATE NER'S TANK 1.D. / D. TANK CAPACITY IN GALLONS: INSTALLED(MO/DAY/YEAR) 11.T ANKS IFA-1 IS MARKED.COMPLETE ITEM C. R LAR 3 DIESEL ❑ 6 AVIATIONGAS A VEHICLE FUEL ❑ 4 OIL B. C. LEADED 4 GASAHOL ❑ 7 METHANOL EUM ❑ 8a EMPTY 7 PRODUCT bUNLEAPREMIUM DED ❑ 5 JETFUEL ALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED A.S. D. #: III. TANK CONSTRUCT N MARK ONE ITEM ONLY IN BOXES A,S.AND C,AND ALLTHAT APPLIES IN BOX D AND W E WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM INGLE WALL ❑ 4 SECONDARY CONTAINMENT [VAULTEDTANK) 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCEJPLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Prlm6ryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 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 1 METHANOL? YES_ NO— r-1 I O_❑ / POLYETHYLENE WRAP ❑ COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION 95 UNKNOWN 91 NONE ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATIONFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 S E L A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 7 STEE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B 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 ❑ 3 MONRORING ❑99 OTHER V.TAN EAK DETECTION/ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATF DATE LAST USED Y/YR) 2 TIMATED QUANTITY OF 3.WAS,TANK FILLED WITH YES NO BSTANCE REMAINING GALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDE LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNAW REI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# � FACILITY# TANK# SHAw�7� STATE I.D.# FT Ul Ll��151 PERMIT NUMBER I P RMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ` FORM V V L `J