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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 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 ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED ONSITE ❑ ❑ 6 TEMPORARY TANK CLOSURE ❑ e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a 3/O/ !1 N. / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.• O/ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYYEAR) D. TANK CAPACITY IN GALLONS: DQ A II.TANK NTENTS IFA-11S MARKED,COMPLETE ITEM C. uC A. :P(A MOTOR VEHICLE 7FUEL ❑ 4 OIL I /, DIESEL PETROLEUM 60 EMPTY -Il PRODUCT UNLEADED PREMIUM 4 GASAHOL ❑ 8 AVIATION GASCHEMICALPRODU ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1bUNLEAD D ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 2 LEADED ❑ gg OyHER (DESCRIBE IN ITEM D. BELOW) D. NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B,AND C,AND ALL THAT APPLIES IN BOX [A. YPE OF ❑�OUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER YSTEM O' 2 ❑ ❑ 95 UNKNOWN LE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBEflGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTICATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRPmary Tank) ❑ g BRONZE ❑ 70 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 AL4KyD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ LINING ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY p u ea orHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 89 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 PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 9 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN p U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR � 2 LINE TIGHTNESS TESTING 71NTERSR7IAL ❑ MONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK L] 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TE 6 STING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ES TIMATEDOUANTITYOF SUBSTANCE REMAININGyE GALL3.WAS TANK FILLED WITH S ❑ ONS INERT MATERIAL? NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY TA�T)R.QAZ3 STATE IBM � 3 PERMIT NUMBER P RMIT APPROVED BV/DATE / PERMI7 EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. • FOROa646