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f STATE OF CALIFORNIA � STATE WATER RESOURCES CONTROL BOARD WyW i g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 3 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �s• I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 0.TANK CAPACITY IN GALLONS: O ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. Ie REGULAR 3 DIESEL 6 AVIATIONGAS A MOTOR VEHICLE FUEL ❑ 4 OIL B. G ❑ UNLEADED 4 GASAHOL PRODUCT ❑ 1b PREMIUM ❑ 7 METHANOL Q 2 PETROLEUM ❑ 80 EMPTY UNLEADED a 5 JETFUEL Q 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 0 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.I: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOK D AND A. TYPE OF ❑ 1 DOUBLE WALL E] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER 1 BARE STEEL O2 STAINLESS STEEL O3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE � ❑ ❑ (PrimaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER 1 RUBBER LINED .Oy 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR Q 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO_ ZX D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION ACU_) PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A (U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL ANDU BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 99 OTHER MONRORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATELAST USE (MO/DAyNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES N SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE I PRINTF BIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION a FACILITY x TANK x STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORME (12-91) 9 -✓e