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STATEOFCALIFORNIA .' ••. `3 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 O 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SI E ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 1-1_9.F'ANK REMOVED G DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO(DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKCO ENTS IFA-11SMARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OILS* C. aUNLEA ED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT O 1b PREMIUM4 GASAHOL ❑ 7 METHANOL UNLEADED O 5 JETFUEL Q 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN O 2 WASTE O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC.ANDALLTHAT APPLIES IN BOXDANDE A. TYPE OF ❑ DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM O B 100!6 METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 0 99 OTHER O 1 RUBBER LINED ❑ 2 ALKYD LINING F-13/EPDXY LINING E:] 4 PHENOLIC LINING C.INTERIOR O 5 GLASS LINING O 6 UNLINED . I/B5 UNKNOWN ❑ 99 OTHER LINING Epl IS LINING MATERIAL COMPATIBLE WITH 1009E METHANOL? YES_JNNYO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP O 2 COATING O 3 V L WRAP Ej 4 FIBERGLASS REINFORCED PLASTIC PROTECTION O 5 CATHODIC PROTECTION a 91 NONE 95 UNKNOWN O 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 IFAPPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION Ark 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 1 HARE 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 WIFRP 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 ❑ 31 99 OTNER MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAD07E MONITORING [::] U OMATIC TANK GAUGING O 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAS USED(MOIDAYIYR) 2.ESTIMATED UANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND 9:1.74E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLINTCASNAME DA E IVRINTEDaSM.NATUREI � • kA LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK#00/ STATE I.D.# m a 3 O 1-,5-1 oil O PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE y 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 UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (12-91) FOR00BR5