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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.MARK ONLY ❑ 1 NEW PERMIT ONE ITEM ❑ ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED ONSITE DBA OR FACILITY NAME WHERE TANK IS INSTALLED; - 6 TEMPORARY TANK CLOSURE r 8 TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS-. SPECIFY IF UNKNOWN rtlw L0—z A. OWNER'S TANK I.D.N C. DATE INSTALLED(MO/DAY/yEAR) B. MANUFACTURED BY: N. v D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. VEHICLE FUEL 04011- 0 4OIL❑ 2 PETROLEUM 9 C. ❑ 1a REGULARFADE ❑ 80 EMPTY 1 RODUCT UNLEADED 3 DIESEL ❑ 3 CHEMICALPRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 6 AVIATION GAS ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STOPED �2 LEADED 5 JETFUEL ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALL THAT APPLIES IN BOX D AND E C.A.S.;: A. TYPE OF ❑ 1 DOUBLE WALL ❑ SYSTEM 3 SINGLE WALL WITH EXTEgIOR LINER ❑ 2 SINGLE WgLI ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) UN99 KN WN S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC (PrimaryTank) ❑ 9 BRONZE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 10 GALVANIZED STEEL ❑ 8 100% METHANOL COMPATIBLE W/FRP C.INTERIOR 1 RUBBER LINED ❑ 85 UNKNOWN ❑ 99 OTHER ❑ ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ OTHER YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 66 UNKNOWN R ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLENTION EQUIPMENT INSTALLED(YEAR) A. SYSTEM TYPE p U 1 Suc B. CONSTRUCTION A U p V 2 PRESSURE A U 3 GRAVITY I SINGLE WALL A U 2 DOUBLE WALL A V B8 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 3 LINED TRENCH q(� UNKNOWN CORROSION A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC A U 99 OTHER A U 5 ALUMINUM A U 6 CONCRETE (PVC) U 4 FIBERGLASS PIPE PROTECTION A PROTECTION7 STEEL W/COATING D. LEAK DETECTION ❑U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AUTOMATIC LINE LEAK DETECTOR p� UNKNOWN q U B 'W" METHANOL COMPATIBLE W/fRP 2 LINE TIGHTNESS TESTING V.TANK LEAK DETECTION MONROgING �99 OTHER ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 6 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWry VI.TANK CLOSURE INFORMATION ❑ 99 OTHER 1.ESTIMATED DATE LAST USED(MO/DAYrYR) 2.ESTIMATED OUANTITV OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND GALLONS INERTMATERIAL? YES ❑CORRECT NO APPLICANTS NAME (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNT-Y# JURISDICTION# CILITY PERMITNUMBER Q O C n PERMIT APPROVED BY/DATE •! O /41 FORM THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION• PERMIT EXPIRATION Dp7E FILE THIS FORM WITH TyI�LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STRRENT FORMA WE TANK REGULATIONS ILED. FORME (12.91) • FORowg-R6