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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD oo es UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 2 INTERIM PERMIT MARK ONLY � 1 NEW PERMIT ONE ITEM ❑ ❑ 3 RENEWAL PERMIT ED5 CHANGE OF INFORMATION c" 4 AMENDED PERMIT 7 PERMANENTLY CLOSED ON SITE O 6 TEMPORARY TANK CLOSURE Oq DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6 TANK REMOVED � I. TANK DESCRIPTION COMPLETE ALL ITEMS- 4 ✓ SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# / C. DATE INSTALLED(MO/DAY/YEAR) B. MANUFACTURED BY: �n mi✓H OL,/✓+ D. TANK II.TANK CONTENTS CAPACITY IN GALLONS: FA-I IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL g C ❑ 1a REGULAR 3 DIESEL ❑ 2 PETROLEUM O 00 EMPTY UNLEADED `n� ❑ 6 AVIATION GAS ❑ 1 PRODUCT ❑ ib PREMIUM �.l 4 GASAHOL ❑ 3 CHEMICAL PRODUCT �-gB UNKNOWN UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.ANDC,ANOALLTHAT APPLIES IN BOXDAND A. TYPE OF ❑ 1 DOUBLE WALL E ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL -- ❑ 4 95 UNKNOWN SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E] 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL El 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM (PrimaryTank) ❑ g BRONZE E] 8 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER 1:31 RUBBER LINED ❑ 2 ALKYD LINING C.INTERIOR ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? UNKNOWN ❑ g9 OTHER VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 3 VINYL E] 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑ 91 NONE L�q �UNKNOWNWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE TION EQUIPMENT INSTALLED YEAR) A. SYSTEM IYFF A U 1 SUCTION A U 2 PRESSURE p U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 3 LINED TRENCH A UNKNOWN A U A 99 OTHER U 2 STAINLESS STEEL A U 3 CORROSION A U 5 ALUMINUM A U B CONCRETE POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE PROTECTION A U 9 GALVANIZED STEEL A U 7 STEE /COATING A U 8 100% METHANOL COMPATISLEW/FRP D. LEAK DETECTION 1 AUTOMATICLINE LEAK DETECTOR CATHODIC PROTECTION <`5',90 UNKNOWN A U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING —�� V.TANK LEAK DETECTION MONITORING M 99 OTHER —_— ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 1 NONE ❑ 95 UNKNOWN VI.TANK CLOSURE INFORMATION 0990 THER 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATEDOUAN717yOP SUBSTANCE REMAINING GALLONS 3 WASNERTMILLERREDIILITH YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED b SIGNATURE) DATE LOCAL AGENCY USE ONLY THE S=I.D.# UMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Y# JURISDICTION# FACILITY# TANK#[;;STATE R C7 ERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. f Z • • FOg0a31&RS�