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STATE OF CALIFORMA 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 B CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.4 B. MANUFACTURED BY: 15 777 C. DATE INSTALLED(MOIDAYNEAR) O D. TANK CAPACITY IN GALLONS: .I O v II.TANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. ,. ❑ ❑ 14UNLEADED REGULAR 3 DIESEL ❑ 1 MOTOR VEHICLE FUEL 6 OIL S. C. 8 AVIATgN GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT OPREMIUM A GASAHOL 7 METHANOL ❑ UNLEADED ET 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LE DED ❑ 99,OTHERL(DESCRIBE IN ITEM D. BELOW) D. IF(AT)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARKONE ITEMONLY IN BOXESA,B,ANDC,ANDALLTHAT APPLES INBOXDANDE A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ % UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER R. TANK ,,L ❑❑ El BARE STEEL ❑ 2 STAINLESS STEEL lyl 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC uY MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 700% METHANOL COMPATIBLE W/FRP (PrimnyTAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ % UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION xg 1 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEG NDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 7 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL DOUBLE WALL A U 3 LINED TRENCH A U % m. WN 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 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 8 100% METHANOL COMPATIBLE W/FRP PROTECTION j U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESSTESTING ❑ 3 INTERSTITRI 99 OTHER MONITORING ❑ V.TANK LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 09 OTHER VI-TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PpWJZr,AND L9 tE BOF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME � DATE (PRINTED A SIGNATUbRE) S LOCAL AGENCY USE ONLY F/THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m 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 WRHWOCAL AGENCY IMPLEMENTING THE UNDERGROUND SIGE TANK REGULATIONS fORMB (12.91) FOROPJI6%