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• . eeoua : o0 STATE OF CALIFORMA STATE WATER RESOURCES CONTROL BOARD' to 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 7 PERMANENTLY CLO D ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /SI y S C.J A(-- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) Lys D. TANK CAPACITY IN GALLONS:L` UOQ ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 18 REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C A S#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑�4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ B. TANK 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 F18ERGLASS ❑ 4 STEEL CLAD W/F113ERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR F75 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH_100%METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑96 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 THER B. CONSTRUCTION A U S GLE WA A U 2 DOUBLE WALL A U 3 LINED TRENCH A U W A U 99 OTHER C. MATERIAL AND A 1 E TEE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U e GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p U 99 O D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31NTFA3T1 mL 98 OTHER MONITORING LE V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH n SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NPS NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LD.# COUNTY# JURISDICTION# FACILITY# TANK# p K" = Y PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATONDATE / ,711,3 FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR99NB-R4 • •/ham