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• STATE OF CALIFORNIA • ." V^•;pS' STATE WATER RESOURCES CONTROL BOARD 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM MARK ONLY t NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER Y SI.OSED ON B ONE REM 2 INTERIM PERMIT F7 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TAN R JVC DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Is I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.• / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYYEAR) 93 D. TANK CAPACITY IN GALLONS: II.TANKCONTEMS IFA•1ISMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 6 OIL la REGUL 8. C. R 3 DIESEL ❑ 6 AVIATIONGAS 2 PETROLEUM ❑ 80 EMPTY M 1 PRODUCT IO PREMIUM 4 GASAHOL I—' 7 METHANOL UNLEADED ❑ 5 JET FUEL tJ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOWI D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,8,AND C.ANDALLTHAT APPLES IN BOX D AND 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 B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATISLEW/FRP (PrimaryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING y<6 UNLINED ❑ 95 UNKNOWN ❑ 9g OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESX 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 IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION p PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AU FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 i AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 71TIT MONITORING E:] 99 OTHER El V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMA D AT ST USED(MOIDAYYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME GATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COU STATE I.D.# NTY# JURISDICTION# FACILITY# TANK# S I ?ERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE WL- THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH TH FORM R (12-91) fAL AGENCY IMPLEMENTING THE UNDERGROUND STORfTANK REGULATIONS a14 /67-1I 1- FORO¢i4&fl6 v..