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PPhOu�rt9�O STATE OF CALIFORNIA P STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B Ye COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT3 RENEWAL PERMIT ❑ ❑ 5 CHANGE OF INFOTANK CLOSATIONURE ❑I��7 TANK REMTLYOVED CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE g TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.If ?—0tD B. MANUFACTURED BY: 1 h C. DATE INSTALLED(MO/DAY/YEAR) nD. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 ISMARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL �01 B. C• ❑ la=EG LAR R 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM❑ 3 CHEMICAL PRODUCT 90 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ ❑ 95 UNKNOWN /yypS� UNLEADED ❑ 5 JET FUEL ILX` ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF �❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �fV 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE - 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING C.INTERIOR ❑ 6 I NNG UNLINED LINING 5 GLASS LI ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE DK5UNKNOWN ❑ 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 U 2 PRESSURE A AV 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p 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 PIPE CORROSION A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL W/COATING A U a 10D% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL CATHODIC PROTECTION p U- 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK D TECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ A MONROflING ❑99 OTHER V.TANK LEAK DETECTION VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST U ED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® = 2 PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMS (1291) FILE THIS FORM WITO LOCAL AGENCY IMPLEMENTING THE UNDERGROUNDS AGE TANK REGULATIONS /�r/L� FOROC61BR6