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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD • UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B COMPLETE A SEPARATE FO e-r RM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 7 RENEWAL PERMIT zr 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ s AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE a 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.# ( - j S. MANUFACTURED BY: G DATE INSTALLED(MO/DAY/YEAR) I D. TANK CAPACRY IN GALLONS: II.TANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. A, ❑ 1 MOTOR VEHICLE FUEL ❑ A OIL S. T-� C. ❑ IaUNLEAOED -?DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 60 EMPTY U f PROOUCT ❑ 10 PREM IUM s GASAHOL ❑ 7 METHANOL UALEADE❑ 0 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LFADEOD Q 5 JET FUEL ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOWI D. IF(&I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXESA,S.ANOC.AND ALL THAT APPLIES IN BOXOANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 0 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [:J I SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK E ' BARE STEEL ❑ 2 STAINLESS STEEL ❑ 7 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F71 RUBBER LINED ❑ 2 ALKYD LANG ❑ S EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR LINING ❑❑ 5 GLASS LINING 6 UNLINED ❑-'95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL 7 YES— NO_ D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ f FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE [::--S'S'UNKNOWN ❑ 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"i1 SUCTION A U 2 PRESSURE A U S GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 0 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U D POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ©'LINE TIGHTNESS TESTING ❑ MONROR9IG ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑"-2 INVENTORY RECONCILIATION ❑ 0 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑-6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN a 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NOQ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED&SK ATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# l�7r pi! Tl STATE LD.# PERMITNUMBER PERM IT APPROVED BY/DA I h PERMIT EXPIRATION DATE l FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. • C�� FORO#NB-RS