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,eeo N STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM Q 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.6 DoH- B. MANUFACTURED BY: (6�� C. DATE INSTALLED(MOIDAYIYEAR) j,C D. TANK CAPACITY IN GALLONS: /co ale— fl.TANK C II.TANKC S IFA-11SMARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ ♦ OIL B. C. ❑ la REGULAR 3 DIESEL ❑ 6 AVIATIONGAS I GASAHOL ❑ 2 PETROLEUM ❑ 60 EMPTY I PRDIXICT ❑ Ib NLEAIUM 5 JET FUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE EZr2 LEADED 99 OTHER (DESCRIBE IN ITEM C. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.6: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 114UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEOTANIQ ❑ 29 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ ! STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDEUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 0 BRONZE ❑ 10 dLLVANIZED STEEL 96 EEEUUUUNNKXXXNYYYOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING 19 LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES— NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 TING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY ACU 99 OTHER S. CONSTRUCTION A U 1 SINGLE vAu. DOUBLE WALL A U 3 LINED TRENCH A U A U 99 OTHER C. MATERIAL AND A BARE STEE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U MINUM A U 6 CONCRETE A U 7 STEELWICOATING A U 8 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 96 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 1 MONTORNAL ❑w OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 V RMONITORING❑ 6 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTTIALMONITORING 91 NONE ❑ 95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED OUANTTY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO LD THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE )PRINTED A S,GN�TNREl LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 6 JURISDICTION 6 FACILITY 6 TANK 6 STATE I.D.# ® d IA PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE EoRM 3 19901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F FA03U M