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'ince$ STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `�y t4•h �a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY E::l 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSF ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE e TANK REMOVED of DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / S ,s A.u � L TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 � B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: goo 0 II.TANKC ENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1a REGULAR EGUL R 3 DIESEL 6 AVIATION GAS A � 2 PETROLEUM O 80 EMPTY 1 PRODUCT 1b PREMIUM GASAHOL 7 METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (OESCRVBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: 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 ❑ DOUBLE WALL F--] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM Ee2 SINGLE WALL F7 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE WIFRP (Primary Tank) 9 BRONZE 1C GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED 2 AILKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ��,,K6/UNLINED ED 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 OATWG 0 3 VINYL WRAP E::] 4 FIBERGLASS REINFORCE[-PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION Ej2l 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U QIEUCTION A U 2 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 AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVCIA U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL000ATING A U 6 100% METHANOL COMPATIBLE W)FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PRCTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR E�D 2 LINE TIGHTNESS TESTING ❑ 9 INTERSTITIAL MONITORING ❑ 99 OTHER V.TANK LEAK DETECT60N ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADCZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING E1 6 TANK TESTING ❑ 7 INTERSTITIAL MOWTORING 91 NONE 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES SUBSTANCE REMAINING GALLONS INERT MATERIAL? NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THF BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE C.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY 1t TANK 4 STATE I.R.# 3 °p / U � �I f PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATIO VE ;ORM a (7.91) THIS FORM MUST BE ACCOMPANIED BY A.PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 / J f FOR00y/&R6