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• STATE OF CALIFORNIA • �zooA es STATE WATER RESOURCES CONTROL BOARD ° UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH T,ANK SYSTEM. EDBAOR LY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ M ❑ 2 INTERIM PER ❑ 4 AMENDED PERMIT 7 PERMANENTLY CLOSED ONSITE ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Q/ ACILITY NAME WHERE TANK IS INSTALLED: G�>e�c r S � I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN a: A. OWNER'S TANK I.D.# ♦7 l L ✓ B. MANUFACTURED BY: u�. C. GATE INSTALLED(MO/DAYAEAR) GCS D. TANK CAPACITY IN GALLONS: O o Uv ^ II.TANKCO NTS IFA-11S MARKED,COMPLETE ITEM C. GL! A. En'1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O eREGULAR n 3 DIESEL ❑ 2 PETROLEUM UNLEADED ❑ e AVIATION GAS ❑ 80 EMPTY 1 PRODUCT ❑ tb PREMIUM LUJ 4 GASAHOL UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 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.#: III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN 13OXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 3 LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 521�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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 Al,K D LINING3 EPDXY LINING ❑ 4 PHENOL LINING ❑ C.INTERIOR / LINING ❑ 5 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ 0 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 3,06ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 9/ NONE D 9 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 2 PR SUR A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGL WA A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A UA 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 PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U B 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN q U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR � 2 LINE TIGHTNESS TESTING ❑ 0 MONROflING ❑99 OTHER V.TANK LEAK DETE TIO ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING E] 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING GALLONS 3.WAS TANK FILLED WITH VES ❑ NO❑ INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D,NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# I.D.# ® rn — � 1 m— SAr,rozz E;;ESTATE PERMIT APPROVED BY/DJATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. • / – FOR000/11-115