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� 0 � un e STATE OF CALIFORNIA W �'� STATE WATER RESOURCES CONTROL BOARD W� ,r, UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B ~;n , 1 I C��I.OXM�� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑-y 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN 67 A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. la REGULAR � 3 DIESEL 6 AVIATION 11 A ❑ 2 PETROLEUM1 MOTOR so FUEL BO OILB.B ❑ 1 PRTUCT [—]❑ 1b PREM UMD LJ 4 GASAHOL ❑ 7 METHANOL AS UNLEADED ❑ 5 JETFUEL 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WA ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.S: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILLAND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 41000s—L IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A D 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 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 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 9 MONITORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 5i�95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO DAY/YR) 2.EBTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E:] NO SUB STANCE REMAINING GALLONS ,MATED THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# NK# CSS STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. • F0800308P5 BAR m ri4nIK ��d �, i &