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STATE OF CALIFORNIA � t; STATE WATER RESOURCES CONTROL BOARD W L I UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B Y COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 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: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0. �TANK RED BY: ��. C. DATE INSTALLED(MO,''DAYNEAR) ca 7 ITY IN GALLONS: ,/ LJ[> 11,TANK CONTENTS IFA-1 IS MARKED,COMPLETEITEMC. A 1 MOTOR VEHICLE FUEL 714 OIL B. C. ❑ 1aUN UNLEADED REGULAR 3 DIESEL ❑ 6 AVIATIDNGAS 2 PETROLEUM F7 60 EMPTY �'\l PRODUCT 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED �❑ 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E 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 Wl FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B t0O% METHANOL COMPATIBLE WIFRP (PrlmaryTank) ❑ 9 BRONZE ❑ 19 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 10046 METHANOL? YES_ NO ❑ 1 POLYETHYLENE WRAP F72 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHODIC PROTECT VON ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 01 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION C((95 UNKNOWN A U 99 OTHER D. LEAK DETECTION F] 1 AUTOMATIC LINE LEAK DETECTOR F] 2 LINE TIGHTNESS TESTING ❑ MONITORING L_] OTHER V.TANK LEAK DETECTION I ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORINGd{�--1 4 AUTOMATIC TANK GAUGING 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING F77 INTERSTITIAL MONITORING ❑ 91 NONE Y"c 5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION YYYtccc 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERT MATERIAL 7 YES L_] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE {PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) FOR043413-R6