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oun es STATE OF CALIFORNIA r 4 STATE WATER RESOURCES CONTROL BOARD �,,• �o C UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.- 14 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 5P s` I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# D B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) /Q/3 Q D. TANK CAPACITY IN GALLONS: O O II.TANK TENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. g 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR 3 DIESEL ❑ e AVIATION GAS UNLEADED 4 GASAHOL ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM ❑ ] METHANOL UNLEADED ❑ 5 JET FUEL ❑ 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 CONSTRU ION MARKONE ITEM ONLY IN BOXES A,B,AND C,ANDALLTHAT APPLIES 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 R F S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC s MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°. METHANOL COMPATIBLE WIFRP r (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER r ❑ 1 RUBBER LINED ❑ LKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP EPr,l 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 IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A UR A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U UBLE WA A U 3 LINED TRENCH A U 95 UNKNOWN A 11 gg p7HBq C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 4 FIBERGLASS PIPE CORROSION A U5 JMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Eyl AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ / 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 ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL] YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IPRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK#OOt PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS AGENT FORM b r�B�N�F)LE� � FOROKM RS