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STATE OF CALIFORNIA "ts °°i / STATE WATER RESOURCES CONTROL BOARD i - I UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W�� H 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 ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -5,-z 9 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 L B. MANUFACTURED BY: y„ C. DATE INSTALLED(MO/DAYIYEAR) D. TANK CAPACITY IN GALLONS: II.TANK CO_NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 7 MOTOR VEHICLE FUEL 4 OIL e_ C 1a REGULAR DIESEL A. O ❑ UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL O 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.o: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.R.AND C,ANDALLTHAT APPLIES IN BOX DANDE A. TYPE OF ❑ 11�DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN SYSTEM E2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTARk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL O 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �l LNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 V L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION F-191 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILLAND 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 AV SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 6 CONCRETE A U 7 STEEL Wt COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION <OIS UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORINGTITW ❑ OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO 7-�- 7- 57-1- SUBSTANCE REMAINING d, GALLONS IINERT MATERIAL? ❑ 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 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW CmOUNTY# JURISDICTION# FACILITY# TANK* SAM05Z STATE LD.# I �I J [T-nI I ILt I glo PERMIT NUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE 15--12-,C3 FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM AA HAS BSN FILED. l/ FOROOMBA6