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i STATE OF CALIFORNIA • ""' `. STATE WATER RESOURCES CONTROL BOARD I UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B C+y o NJ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. I ` MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 12KS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ON 917E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYIYEAR) L. D. TANK CAPACITY IN GALLONS: II.TANKC9NfENTS IF AA ISMARKED,COMPLETE ITEM C. 4 OIL 1 MOTOR VEHICLE FUEL ❑ IAREGULAR 3 DIESEL A. ❑ B. C• UNLEADED 4 GASAHOL ❑ S AVIATIONGAS ❑ 2 PETROLEUM ED so EMPTY E'I PRODUCT ❑ Ib PREMIUM ❑ 7 METHANOL UNLEADED 6 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 06 UNKNOWN ❑ 2 WASTE JG : ` LEADED ® W OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXESA,0,AND C,AND ALL tHATAPPLIES INB0XD�� A. TYPE OF F-] L:7 5I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) - ❑ 00 OTHER 8. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 6 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 1 ALUMINUM ❑ 6 ISO% METHANOL COMPATIBLE WARP (Prlmuy TAnk) ❑ 0 BRONZE ❑ 10 GALVANFtED STEEL 21-OS UNKNOWN ❑ 00 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ /3 EPDXY LINING ❑ 4 PHENOLb LINING C.INTERIOR ❑ 6 0LA99 LINING El UNLINED LINING C?1 05 UNKNOWN ❑ 00 OTHER 19 LINING MATERIAL COMPATIBLE WITH 1W% METHANOL YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP. ❑ 4 PIBERGLASE REINFORCED PLASTIC PROTECTION ❑ 6 CATHODIC PROTEDTION❑ 91 NONE d95 UNKNOWN ❑ 00 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 9 PRESSURE A U 3 GRAVITY . A U 90 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A E95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I SAFE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 6 ALUMINUM A U 0 CONCRETE A U 7 STEELW/COATING A U 6 IW% METHANOL COMPATIBLE W/FRP _ PROTECTION A U 9 GALVANr2ED STEEL A U IO CATHODIC PROTECTION A 06 UNKNOWN A U 00 OTHER. D, LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR+ ❑ 2 LINE TK34TNESS TESTING ❑ 3 INTERSTITIA MONITORNO ❑ 00 OTHER V.rTANK LEAK DETECTION u I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC LANK GAUGING ❑ 6 GROUNDWATER MONITORING ❑ 0 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 05 UNKNOWN ❑ 00 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED 0UANTRY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DAZE IPMNTED 9 SIONATIIREI - LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION N FACILITY# TANK# STATE I.D.# FilLm- PERMITNUMBER - PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE l e. FORM B (4901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORSSHB-Rd 0