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• STATE OF CALIFORNIA e�,eouA ey STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 3 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT °4pge' ❑ ONE ITEM ❑ ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 2 INTERIM PERMIT E-] 4 AMENDED PERMIT ❑ 7 MANENTLY CLOSED ONSITE DB6 TEMPORARY TANK CLOSUREA OR FACILITY NAME WHERE TANK IS INSTALLED: B TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.x C. DATE INSTALLED(MO/OAV/.---1 B. MANUFACTURED BY: 1�- D. TANK CAPACITY IN GALLONS: l/ II.TANK CON S -'Q 00 IFA-1 ISMARKED,COMPLETE ITEM C. A. UV MOTOR VEHICLE FUEL ❑ 4 OIL B to REGULAR ❑ 2 PETROLEUM ❑ BO EMPTY C. ❑ UNL Bp ❑ 3 DIESEL ❑ 6 AVIATION GAS 1 PRODUCT ❑ 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ IDP MIUM ❑ 95 UNKNOWN ❑ 2 WASTE NLEADED ❑ 5 JE7FUEL ❑ T METHANOL D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED 2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTIO MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND E C A.S.x: A. TYPE OF ❑ DOU LE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 SYSTEM INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER UNKNOWN B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGI ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 6 POLYVINYL CHLORIDE ❑ 7 MINUM (PrimaryTank) ❑ 9 BRONZE ❑ B 100q METHANOL COMPATIBLE W/FRP ❑ 10 GALVA D STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED IS LINING MATERIAL COMPATIBLE WITH 100% METH OL 7 ❑ 95 UNKNOWN ❑ gg OTHER YES_ NO_ D,CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 TING PROTECTION ❑ 3 VINYL WgAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH OVERFILL F APPLICABLE TION EOUiPMENT INSTALLED YEAR) A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALLA U OTHER C. MATERIAL AND A U 1 BARE STEEL A U 3 LINED TRENCH A U 9 UNKNOWN A U 99 OTHER A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLOKIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM p U 8 CONCRETE PROTECTION A U 9 GALVANIZED STEEL U 7 STEEL 5 COATING A U 9 100% METHANOL COMPATIBLE WIFgP D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK TECTOq CATHODIC PROTECTION A U g5 UNKNOWN EA U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING 3 V.TANK LEAK DETECTION MONITORING ❑ 99 OTHER_ El 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIAT 8 TANK TESTING ❑ 7 INTERSTITIAL MONIRING ION ❑ 3 ZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING 91 NONE 95 UNKNOWN ❑ 5 GROUND WATER MONITORING ❑ TO ❑ VI.TANK CLOSURE INFORMATION ❑ 99 OTHER 1.ESTIMATED DATE LA T USED MO/DA 11'R) 2.ESTIMATED QUANTITY 61 ^ l SUBSTANCE REMAINING (/ GALLONS APPLICANT'S NAME 3 WAS TAN A ❑ FILLED WITH YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# c PERMIT NUMBER C � PERMIT APPROVED BV/DATE PERMIT EXPIRATION DAT{/ FORM B (7-91) THIS FORM MUST BE ACCOMPANI17— ED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. II1 FORDWOp\�v�U