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u STATE OF CALw&tMA - 'o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B y� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY ❑ ONE REM ❑ 2 INTERIM PERMIT � 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / z5- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: U A. OWNERS TANK I.D.# D. TANK CAPACITY IN C. DATE INSTALLED(MO( AYNEAR) '7- /-J5 GALLONS: (,� II.TANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. 1a REGULARJUM n 3 DIES7(DESCR�IBE 6 AVIATIONGAS LIFMOTOR VEHICLE FUEL 4 OIL B. C. ❑ UNLEADED LY J9 q GASA7 METHANOL PETROLEUM ❑ BO EMPPREMIUM TV 1 PRODUCT ❑ 1bUNLEADED O 5 JET FCHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE O 2 LEADED ❑ 99 OTHN ITEM D.BELOW)NOT MARKED. ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S,AND C,AND ALL THAT APPLIES IN BOX D AND 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINERtLINING UNKNOWN A. TYPE OF ❑ ❑ 4 SECONDARY CONTAINMENT (VAULTEDOTHER SYSTEM ❑ 2 SINGLE WALL O 1 BARE STEEL � 2 STAINLESS STEEL O 3 FIBERGSTEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 6 POLYVINYL CHLORIDE 7 ALUMIN100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (P11mmryTmk) O 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOTHER 1 RUBBER LINED ❑ 2 ALKYD LINING E3 EPDXY074 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN O 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO ❑ 1 POLYETHYLENE WRAP E] 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EGUIPMENT INSTALLED(YEAR) 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 A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH dl> 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 W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 1v UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 0),gNRORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK E::] 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING F] 7 INTERSTITIAL MONITORING ❑ 91 NONE tbar.95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION --- 1.ESTIMATED DATE LAST USED ?/DDAAY 2.ESTIMATED QUANTITY OF 3.W TANK FILLED W ITH YES a NO LD SUBSTANCE REMAININ GALLONS ERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR THE BEST KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# /- STATE I.D.# r7 p '45.r PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH`HF LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STOPAC�G / ��J 1 ANK R U A10 OR00 896 j� FORM B (1291)