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• • e STATE OF CAUFORMA °� STATE WATER RESOURCES CONTROL BOARD W v e UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ��`�""'"�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5Z17D R w`7 q? I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK LD.# ca I S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) vJ—� D. TANK CAPACITY IN GALLON II.TANK CONTENTS IFA-1 IS MARKED.COMPLETEITEM C. A. MOTOR VEHICLE FUEL ❑ 4 OIL B. C.� Ia REGUL R 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY1 PRODUCT ❑ lb PREMIUM 4 GASAHOL ❑ 7 METHANOL "`"""ttp UNLEADED 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALLTHAT 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 B. TANK ❑ 1 BARE STEEL F7 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 7 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL IN 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 121,95 UNKNOWN ❑ 99 OTHER LINING- IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL I YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING I❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 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 1 SUCTION A/52 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN p 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 PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U UNKNOWN A U 99 OTHER D. LEAK DETECTION Q,5Z AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MDNRORNC ED 99 OTHER V.TANK LEAK DETEC ION ❑ 1 VISUAL CHECK2 INVENTORY RECONCILIATION E] 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING r7 INTERSTMALMONTTORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYHR) I 2.ESTIMATED OUANTTTY OF 3.WAS TANK FILLED WITH YES [:3NO ❑ 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 IPRIYTED 6 SIGNAWRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# I PERMIT NUMBERPERMIT APPROVED BY/DATE )PERMIT EXPIRATION DATE �3 9S FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 0 FOR00N&0.5