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• STATE OF CALIFORNIA . 4A- MARK STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FOR E TA K SYSTEM ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 5 CHAN E OF INFORMATION O 7 PERMANENTLY CL ITE 6 TE RARY TANK CLOSURE a TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: If k7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BV: (lc_ C. DATE INSTALLED(MO/DAYA'EAR) L/((' D. TANK CAPACITY IN GALLONS: /ULOOD IL TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL q OIL BKE9"'IPRODUCT C aREGUaF ❑ 3 DIESEL 2 PETROLEUMUNLEADED ❑ 6 AVIATIONGAS ❑ ❑ BO EMP1V ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 LNELADEDED ❑ 5 JET FUEL D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED ❑ OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑,'DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ g5 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 SARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 KYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED LINING ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES _ D.CORROSION ❑ 1 POLYETHYLENE WRAP Fp COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑95 UNKNOWN O W OTHER IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION q 2 PRESSURE A U 3 GRAVITY p U 99 OTHER B. CONSTRUCTION A U LE W A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A V 99 OTHER C. MATERIAL AND A U A U 2 STAINLESS STEEL A U 3 POLTVINYL CHLORIDE(PVC)# U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION L:j 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTINGMONFO 3 IMNFO I IAL ❑ RING ❑ 99 OTHER V.TANK LEAK DETECTION E-1 I VISUAL CHECK 2 ❑ 6 TANK TESTING ❑ 7 INTERSOITA RMON TORING N ❑ g7VN0 EAPOR MONITORINGQ 95 AUTOMATIC UNKNOWN TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USEDMO/ AV/YR) 2.ESTIMATED QUANTITY OF 3 `t 'j SUBSTANCE REMAINING GALLO3.WAK FILLED WITH S TAN ❑ U�� NS NERT MATERIAL 7 YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATURE( DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK .'W1�=p_r STATE LDA ® V M PERMIT NUMBER PEflMIT APPflOVED BV/DATE V PERMITEXPIgATIOIN DATE - - FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. p FOg0IXi4Bg4