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0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD r UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B � COMPLETE A SEPARATE FORM FOR E5WPANK SYSTEM. MARK ONLY 1 NEW PERMIT �' 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAACLO�SEDONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 9 TANK DBA OR FACILITY NAME WHERE TANK IS INSTALLED: g �d I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a B. IMNUFACTURED BY: O c JM C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS:ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. Al MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1eUNLEA ED REGULAR 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ W EMPTY 1 PROD(1CT 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WABTE U 2 LEADEDD 99 JOTHER L(DESCRIBE IN ITEM D. BELOW) I D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALLTHAT APPLES IN BOX D AND A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMTTE�ENNT,,(VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL X3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC F] F-1MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ..��❑—,y/ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING Ix 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL 7 YES X NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEG UNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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&> FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 IOD% 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 Vl AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 2 MONITORING ❑ 99 OTHER V.TANK LEAK DET TION ❑ 1 VISUAL CHECK F72 INVENTORY RECONCILIATION F--] 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATE R MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING F791 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATE A LAST SD(MO/DAY/YR) 2.ESTIMATEDOUANTITYOF 3.WAS TANK FILLED WITH YES ❑ NO � SUBSTANCE REMAINING GALLONS INERT MATERIAL THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRI WED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY R JURISDICTION p FACILITY# TANK# 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. FORM B (12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS. 7 FOR00318-R6 • 0 4-��