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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD U NDERGROUND STORAGE TANK PERMIT APPLICATION FORM B � COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. [D;BA K ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE E ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 6 TANK REMOVED OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY: A. OWNER'S TANK 1.D.M C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. is REGULAR 3 DIESEL ❑ 6 AVIATIONGAS' 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. Q• ❑ UNLEADED q GASAHOL A. 1 PRODUCT tb PREMIUM ❑ 7 METHANOL 2 PETROLEUM ❑ SO EMPTY ❑ UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALLTHAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ w OTHER SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) P1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC N ❑ g pOLWINVL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLEW/FRP ❑ 5 CONCflETE❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING ❑ UNLINED ❑ 95 UNKNOWN99 OTHER 5 GLASS LINING LINING MATERIAL COMPATIB ..��WI55TH 100%METHANOL 7 YES NO_ ❑ 1 POLYETHYLENE WRAP2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ ❑ 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 p PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A?5 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN p U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMAT CLINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ OTHER V.TANK LEAK DETECTION ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 7 VISUAL CHECK ❑ 99 OTHER 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES ❑ NO 1.ESTIMATED DATE L T US ( 0/DAWIVR) 2.ESTIMATED QUANTITY OF _ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, E IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 8 SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY- � TANK# STATE LD.# JI� PERMIT NUMBER PERMIT APPROVED BY/DATE 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 REGU^L�ATIONSL'r6 FORO,3/6R6 FORM (12-91) 0 (IJ/ 0 1