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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD tenon r UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B o4 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT o'enonn•e ONE ITEM ❑ ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 7 PERMANENTLY CLOSED ON SITE e TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z6i� e TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 2- G A. OWNER'S TANK I.D.a G DATE INSTALLED(MO/DAV/YEAR) � B. MANUFACTURED BY: G ' D. TANK CAPACITY IN GALLONS: !' It.TANK CONTENTS IFA-1 IS MARKEO,COMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ A OIL B C 1e REGULAR ❑ 2 PETROLEUM 80 EMPTY ❑ UNLEADED 3 DIESEL 1 PRODUCT ❑ 7b PREMIUM 4 GASpHOL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 2 WASTE \ 2 LEADED D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY INBOXESA,8,AND C,ANDALLTHATAPPUESINBOXD NDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL El 95 OTHER SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 6 CONCRETE ❑ 3 FIBERGLASS E] 4 STEEL CLAD We FIBERMA ❑ 8 POLYVINYL CHLORIDE E] 7 ALUMINUM El 10 GALVANIZED STEEL OK 95 UNKNOWN SS REINFORCED PLASTIC (PrimaryTank) El BRONZE ❑ B 100x, METHANOL COMPATIBLE WiFRp C.INTERIOR El2 ALKYD LINING 1 RUBBER LINED ❑ 99 OTHER ❑ ❑ 3 EPDXY LINING LINING ❑ 5 GLASS LINING ❑ 4 PHENOLIC LINING ❑ 8 UNLINED 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? O ❑ 99 OTHER YES_ ryO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATINGI� PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE C�--' 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 6 UNKNOWN ❑ 99 OTHER RFILL PREVEN IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH EF APPLICABLE TION EOUIPMENTINS7ALLE0 MAR) A. SYSTEM TYPE A U 1 SUCTION B. CONSTRUCTION A U A U 2 PRESSURE A U 3 GRAVITY 1 SINGLE WALL A U 2 DOUBLE WALL A U W OTHER C. MATERIAL AND A U 1 BAREST A U 3 LINED TRENCH 5 UNKNOWN CORROSION p U 2 STAINLESS STEEL A 99 OTHER A U 5 ALUMINUM A p U 3 POLYVINYL CHLORIDE(PVC)# U 4 FIBERGLASS PIPE PROTECTION A U U 6 CONCRETE A U 7 STEELW/COATING 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UA B 8 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION 7 AUTOMATIC LINE LEAK DETECTOR UNKNOWN A U 99 OTHER ❑ 2 LINETIGHTNESSTESTING 0 A —'� V.TANK LEAK DETECTION MONITORING ❑99 OTHER_ ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER❑ B TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE Imo, VI.TANK CLOSURE INFORMATION 95 UNKNOWN ❑ 99 OTHER 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3 WpS TANK FILLED WITH NERT MATERIAL? YES THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANDCORRECT ❑ NO APPLICANTS NAME IPRINTEO a SIGNANNEI DprE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# O FACILITY# TANK# PERMITNUMBER PERMIT APPROVED BV/DATE PERMIT E%PIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) IA- 61151- K- FOR00348-R6