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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY NSI \V` ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ e TANK REMO DBA OR FACILITY NAME WHERE TANK IS INSTALLED:ct I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# q lN' f B. MANUFACTURED BY: Vy Yl_ C. DATE INSTALLED(MO/DAYNEAR) .1 4Y D. TANK CAPACITY IN GALLONS: II.TANKCONT NTS IFA-11S MARKED,COMPLETE ITEM C. li lJ A. MOTOR VEHICLE FUEL 4 OIL ) ❑ B. 1a REGULAR 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT C ❑ IbPREMIUMUNLEA4 GASAHOL ❑ ° ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL 11 ❑ ❑ 2 LEADED ❑ 9B D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITHEXTERIOR LINER ��/ ❑ 95 UNKNOWN SYSTEM LJ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PlimaryTank) ❑ 9 BRONX GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ( LINING ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOS W_R D.CORROSION ❑ t POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VI NY ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION '❑ 91 NONE 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 I SUCTION p 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 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(PVC) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 ST LW/COATING PROTECTION A U 9 GA NIZED STEEL A U 8 100% METHANOL COMPATIBLE W/FRP A U 10 CATHODIC PROTECTION p 11 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION AUTOMATICLINELEAKDETEC70R INE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION FF,�' VISUAL CHECK INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY O SUBSTANCE REMAININYES ❑ NO 3.WAS TANK FILLED WITH GALLONS ❑ INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAL R✓U , APPLICANTS NAME THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO-RNUMBERS BELOW STATE LD.# COUNTY# JURISDICTION# FACILITY# TANK# m a 3y d2 PERMIT NUMBER PERMIT APPROVED BY/DATE / PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. -J B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS qq /a FOR90348-R5