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w. STATE OF CAIIFORMA • � � �°*� STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W p Y/ Y� O • fpi ttl• COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED 8✓ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �op GDQ� �✓� ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNEFTS TANK I.D.• t - L• ! B. MANUFACTURED BY: tw C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: a 1bUN UNLEADED II TANKrnNTENTS IPA-11SMARKED_ C0MPLETEITEMC. 1 MOTOR VEHICLE FUEL 4 OIL A. ❑ B. lm REGULAR C. 8 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY Q� I -w 1 PRODUCT a 1bUN UNLEADED ❑ d GASAHOL 5 JETFUEL ❑ ]METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN WASTE WASTE O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. s: III_ TANK CONSTRUCTION MARK ONE REM ONLY IN BOXES A.B.AND C. AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK)�❑99 OTHER CONSTRUCTION ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS L ,,,/////11 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM U S 100Ye METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER LEAK DETECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING��❑��^//////JJJJJJ3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ W OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ES_ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 0 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A&A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A( 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 F18ERGLASS PIPE 7 STEEL W/ COATING AU 1W% METHANOL COMPATIBLE W/FRP A U 95 UNKNO AW999 OTHER Z!Q e D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING Ef MONITORING [:]9B OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING /I 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 YESNO SUBSTANCE REMAINING 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 (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY I JURISDICTION I FACILITY I I TANK I U-MKSTATE I.D.# m 2 PERMIT NUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCA71ON - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. • FOR0OAIM •