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i STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 3 } COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 5 CHANGE OF INFORMATION ❑� 7 PERMANENTLY CLOSED ONSITE 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 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.# /a �! B. MANUFACTURED BY: /, f/ C. DATE INSTALLED(MO/DAYIYEAR) / D. TANK CAPACITY IN GALLONS: II.TANKCQNTENTS IFA-115MARKED,COMPLETEITEMC. A. L6 1 MOTOR VEHICLE FUEL ❑ 4 OIL B C [LJ -REG ❑ 3 DIESEL ❑ 2 PETROLEUM ❑ UNLEADED ❑ 8 AVIATION GAS &0 EMPTY �1 PRODUCT ❑ 1bPREMfUM ❑ 4 GASAHOL ❑❑ 7 METHANOL 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADEDEO ❑ 5 JETFUEL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL ❑ ❑ 95 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS -- MATERIAL ❑ 5 CONCRETE ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FHP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C.INTERIOR ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED �g5 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES, NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 -VINYL WRAP `—� PROTECTION ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED{YEAR) W.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A'�i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 1 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 S ALUMINUM ,p U 6 CONCRETE PROTECTION A U 7 STEEL W/COATING A U 9 100°i METHANOL COMPATIBLE WIFRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION q�g1�D5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 VONITOAING ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 G 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑� 91 NONE ROUND WATER MONITORING ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF SUBSTANCE REMAINING 3. �TANKFILLED WITH GALLONS MATERIAL7 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 d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.Q.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW DATE COUNTY# JURISDICTION# FACILITY# STATE I.D,# � TANK# PERMIT NUMBER PERMIT APPRDVED BYIDATE _ PERMIT EXPIRATION DATE FORM a (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. 1� FOR0670-B5