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t.euwces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a ` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B v��- �; COMPLETE A SEPARATE FCRM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ON S/Tell ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED // DBA OR FACILITY NAME WHERE TANK IS INSTALLED- 1. /// I. TANK DESCRIPTION COMPL-EfE-ALLITEMS-- SPECIFY UNKNOWN A. OWNER'S TANK I.D.# © B. MANUFACTURED BY: l✓ h C- C. C. DATE INSTALLED(MO/DAY EAR) ) D.D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA- COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL ® C ❑ 1a REGULAR ❑ 3 DIESEL 6 AVIATION GAS UNLEADED q GASAHOL ❑ 2 PETROLEUM ©�60 EMPTY 1 PRODUCT ❑ lbPREMIUM ❑ 5 JET FUEL FeP 7 METHANOL ❑ 3 CHEMICALPRODUCT 95 UNKNOWN WASTE 2 LEADED g9 pTHER (DESCRIN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED // roller- (c�✓1 C A S III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,R,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF b---2 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAU TED TANK) ❑ 99 OTHER_ B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 400% METHANOL COMPATIBLE WfFRP (Primary Tank) F-1 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 5 GLASS LINING 1 RUBBER LINED 2 Y �-6UNLINED D LINING E] 3 EPDXY LINING 4 PHENOLIC LINING I- LINING L_J ❑ 95 UNKNOWN 7] 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VI RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV,PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUN OTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A6J GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 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 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PgPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING A U 8 1004; METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING -3-IN= NONITORING [-] 99 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 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION L. ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK PILLED WITH SUBSTANCE REMAINING GALLONS INF RT MATERIAL? 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW '�CJ COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# = f.�� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEE ILED, 4 a kN (� 0348-R5