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0 • 09 ^ e STATE OF CALIFORNIA ' ` STATE WATER RESOURCES CONTROL BOARD �� o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ]/PERMANENTLY CLOSED ONSITE � ONE ITEM E] 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 1/8 TANK REMOVED DBA R FACILITY NAME WHERE TANK IS INSTALLED: �Y I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.# 5 1 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) lqTq 0. TANK CAPACITY IN GALLONS: ICl LU ILTANKCONTENTS IFA-1 IS MARKED,COMPLETZ ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1aUN LAR IDEDn�j 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ib PREMIUM U 4 GASAHOL 7 METHANOL ❑ 3 CHEMICALPROOUCT ❑ 95 UNKNOWN O 2 WASTE ❑ 2 LEADEDD ❑ 5 JETFUEL ❑ OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED o L. C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT 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 (VAULTEDTANK) ❑ 99 OTHER S. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [j2165'UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING6 UNLINED 5 UN LINING ❑ ❑ 9KNOWN ❑ 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 UNKNOWN O 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@ 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 01 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 PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 10D% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A095 UNKNOWN p U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONROgING ❑ 99 OTHER V.TANK LEAK DETECTION V1,VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING L�/6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST S ( /DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH . �" SUBSTANCE REMAINING GALLONS I INERTMATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICTS NAME )PRINTED bANSIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LDA ® ® v d 2 p 0 a 5 PERMITNUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATIO E THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HA9 BEEN FILED. FILE THIS FORM WITH 6LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST AQPTANK REGULATIONS FORM B (12-91) 1y 7y�� �✓ FORON4BB8