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STATE OF CALIFORNIA ,,..+°V9 tr STATE WATER RESOURCES CONTROL BOARD .P oo' UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B 3 vO Yt 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM oa„o,,,,,� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 A [D 5 CHANGE OF INFORMATION MENDED PERMIT ❑ g TEMPORARY TANK CLOSURE 7 PERMANENTLY CLOSED ONSITE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l� e TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# (MO/DAY/YEAR) . K B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) . JK �i . D. TANK CAPACITY IN GALLONS: II.TA KCONTENTS FA.7ISMARKED,COMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR 3 2 PETROLEUM DIESEL ❑ ❑ 80E UNLEADED ❑ 6 AVIATIONGAS 1 PRODUCT❑ ❑ 76 PREMIUM 4 G3 CHEMICAL PRODUCT ASAHOL❑ 95 UNKNOWN UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 2 WASTE 2 LEADED D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED ❑ OTHER (DESCRIBE IN ITEM D, SELOM III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND E C.A.S.#: A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL ❑ 4 95 UNKNOWN SECONDARY CONTAINMENT (VAULTEDTANK) E199 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ (Primary Tank) ❑ 9 BRONZE ❑ 9 100% METHANOL COMPATIBLE W/FRP 70 GALVANRED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C.INTERIOR 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ e UNLINED IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 95 UNKNOWN ❑ 99 OTHER YE _ NO_ D,CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION5 ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ CATHODIC PROTECTION ❑ 97 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) RFILL IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH EF APPLICABLENT ON EQUIPMENT INSTALLED YEAR A. SYSTEM TYPE p U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL p U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 3 LINED TRENCH A�95 UNKNOWN A U 99 OTHER CORROSION A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE A U 5 ALUMINUM p U a CONCRETE PROTECTION A U 9 GALVANIZED STEEL I U 7 STEEL UNKNOWN A U 8 100% METHANOL COMPATIBLE W/FRP A U 6 CATHODIC PROTECTION UNKNOWN D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR �5 A U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING � —�� V.TANK LEAK DETECTION MDNRDRING ❑ 9e oTHEq— — ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADpg MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 1*195 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITYOF SUBSTANCE REMAINING 3 WAS TANK FILLED WITH TH/S FORM HAS BEEN COMPLETED GALLONS INERT MATERIAL YES ❑ NO❑ UNDcn PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, !S TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATUREI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION L1IX! STATE LDA TANK PERMIT NUMBER PERMIT APPROVED BV/DATE �V/a/ �' PERM.,EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WR LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STT E TANK REGULATIONS Ik FORM B (72-91) Q Lk 011 Bq