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rt6puaces STATE OF CALIFOFNA z; STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �o ` COMPLETE A SEPARATE FORM FOR EACfi TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSELMZITf ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DSA OR FACILITY NAME WHERE TANK IS INSTALLED: -7 7 Lv c x vr1 C/7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I,D.4 0 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS: ,G, ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. I—I 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 18UN EADED 3 DIESEL ❑ 8 AVIATIONGAS A. ©u'22 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEWCALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. TF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.x: TIL TANK CONSTRUCTION MARK ONE ITEM ONLY tN BOXES A,B,AND C.AND ALLTHAT APPLIES IN BOX D A TYPE OF ❑ 1 UBLE WALL ® 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SI LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL Q 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WlFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED [� 2 �LKID LNING ❑ 3 EPDXY LINING E::] 4 PHENOLIC LINING C.INTERIOR El 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION Q t POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 V NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN 0 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U jr UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U sUCT1 A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U tSI LE WAL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U t 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 8 CONCRETE A U 7 STEEL Wi COATING A U 8 100% METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL p U 10 CATHODIC PROTECTION p U 9 UNKN WN A U 99 OTHER D. LEAK DETECTION ❑ t AUTOMATIC LINE LEAK DETECTOR E 2 LINE TIGHTNESS TESTING 5 INTERSTITAL 99 OTHER ❑ MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VL TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST✓/USED(MOIDAYNR) 2. STIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [—] NO �-/ 1 S_/;/j � SUBSTANCE REMAINING O 0 GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRPNTED S SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# ,JURISDICTION# FACILITY# TANK# STATE I.D.# FTF7 I o I d i FT7 ' PERMIT NUMBER PERM IT APPROVED BY/OATE j PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00U&R4