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a yyy STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i Wim, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7/PERMANENTLY CLO SIT ONE REM F-12 INTERIM PERMIT F-14 AMENDED PERMIT ❑ a TEMPORARY TANK CLOSURE �d TANK REMOVED 4 ��A1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (Vt 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D. B. MANUFACTURED BV: C. DATE INSTALLED(MO/DAYNEAR) `�k D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 ISMARKEDCOMPLUE ITEMC. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ IaREGULAR UNLEADED 3 DIESEL ❑ g AyIATK]N GAS 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1bUNLEAIDEO ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 4095 UNKNOWN ❑ 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.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER S. TANK1 BARE STEEL ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PAmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 05 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED n, UNKNOWN ❑ 99 OTHER LINING '-6p IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? V S_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION E::] 91 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATI N CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLK:ABLE A. SYSTEM TYPE , SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION AV , 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 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A V 5 ALUMINUM A U 0 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 TE STING ❑ 7 MONITORING ❑g9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 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 SUBSTANCEREMAINING GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED ND P ALTY OF P TURP,AND TO THE BEST OF MY KNOWLEDGE, IS TUE AND CORRECT APPLICANTS NAME DA (PRINTED 8 SIGNATURE) 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 o 1 1 PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE / / � THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILE (O Y FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) - F0R0Q4BR5