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x STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ��6oup e UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B uo COMPLETE A SEPARATE FORM FOR MARK ONLY ❑ 1 NEW CH TANK SYSTEM. ONE ITEM PERMIT O 3 RENEWAL PERMIT `•i�.o.H� ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 5 CHANGE OF INFORMATION DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ❑ 6 TEMPORARY TANK CLOSURE ❑ 7 PERMANENTLY CLOSED ON S // ❑ e TANK REMOVED I. TANK DESCRIPTION A. OWNERS TANK I.D.x COMPLETE ALL ITEMS-. SPECIFY IF UNKNOWN C. DATE INSTALLED(MO/DAY/YEAR) B. MANUFACTURED BY: If.TANK CD TANK CAPACITY IN GALLONS: _ ENTS IFA-115MARKEO, A. 1 MOTOR VEHICLE FUEL COMPLETEITEMC. ❑ 2 PETROLEUM ❑ 4 OIL B O 1a REGALE: ❑ 3 DIESEL 60 EMPTY 1 P:ODUCT UNLEADED ❑ 3 CHEMICAL PRODUCT ❑ 16 PREMIUM ❑ 4 GASAHOL ❑ 6 AVIATION GAS 95 UNKNOWN UNLEADED D. IF(q,7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 WASTE --S��JET FUEL ❑ 7 METHANOL - ' ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM NLV IN BOXESA,8,AND C,AND ALL THAT APPLIES IN BOX D AND C.A.S.#: A. TYPE OF ❑ 1 DOUBLE WALL SYSTEM 3 SINGLE Al 111 WITH EXTERIOR LINER ❑ 2 SINGLE WgLL ❑ 95 UNKNOWN B, TANK 1 BARE STEEL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER ❑ ❑ MATERIAL ❑ 5 CONCRETE STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC (Primary Tank) ❑ 6 OLVVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 BRONZE ❑ 10 pLVANIZEC STEEL ❑ ❑ 6 100% METHANOL COMPATIBLE W/FRp ❑ 1 RUBBER LINED 95 UNKNOWN C.INTERIOR ❑ 99 OTHER ❑ 2 AL D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 6 GLASS LINING ❑ 6 UNLI D ❑ 95 UNKNOWN ❑ 89 OTHER IS LINING MA7EglAl COMPATIBLE WITH 100%M THANOL 7 YLENE D.CORROSION ❑ YES— NO_ 1 POLYETHWqpp ❑ 2 COATING PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IF ABOVE GROUND OR U DERGR A. SYSTEM TYPE p U 1 SUCTION IFU )UND,BOTH IF APPLICABLE A U 2 PgESSURE A U 3 GRAVITY B. CONSTRUCTION A U 7 SINGLE WALL p U 2 DOUBLE WqL p U 99 OTHER C. MATERIAL AND A U 1 BARE STEELA U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U S ALUMINUM CORROSION p U 2 STAINLESS STE A U 3 POLYVINYL CHLORIDE(PVC) p U 6 CONCRETE A U d FIBERGLASS PIPE PROTECTION A U 9 GALVANIZED STEEL A U 7 STEEL W/COATING A U a 10096 METHANOL COMPATIBLE W/FRP U D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOq CATHODIC PgOTEC ON A 95 UNKNOWN A U 99 OTHER ❑ 2 IINETIGH ESSTESTING3 o V.TANK LEAK DETECTION D MONITORING ❑99 OTHE ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING TANK TESTING INTERSTITIAL MOED 5 GROUND WATER MONITORING �/ ❑ 6 MONITORING ly. ❑ 91 NONE ❑ 95 UNKNOWN VI.TANK CLOSURE INFORMATION ❑ OTHER r. r w wrFcwsrus o�,vaognyq/ 2.ES71MATH QUANTITY OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH YE ATERIAL YES THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# STATE I.D.# —T FACILITY p TA�KTn PERMITNUMBER PERMIT APPROVED BY/DATE LI 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. 0 0 FOROro B-RS