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.,1 STATE OF CALIFORNIA c` 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 ❑ 5 CHANGE OF INFORMATION MANENTLY OLD ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED 129 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.6 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 000 ILTANKCONTENTS IFA-11SMARKED.COMPLETEITEMC. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C�RELEADE 3 DIESEL ❑ 8 AVIATION GAS UNLEADED 4 GASAHOL 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1bUPMIUM NEAD D 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL-PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E] 2 LEADED g 99 OTHER (DESCRIBE IN ITEM D. BELOW D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.6 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 99 OTHER SYSTEM .SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE 00❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 1 % METHANOL COMPATIBLE W/FRP ❑ (PNm6ryTAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LW WG ❑ 3 EPDXY LINING I-}❑-A 4 PHENOLIC LINING ��,(� C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED E] 95 UNKNOWN 99 OTHER - - -LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 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 INFORMATI CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 4ELP SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL ANDAfU-ji BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL W/CCATING A U B 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MDNIfORING ❑ 99 OTHER J V.TANK LEAK DETEC_�T--IIO))IIN ❑ 1 VISUAL CHECK�L 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND W.A♦TER ONITORING ❑ 6 TANK TESTING/❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN �99 OTHER}N VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNRI 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING -GAL INERT MATERIAL? YES ❑ NO THIS FORM HAS BEE D D OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME e—, DATE r� (PRNITEG A SIGNATUR P /� (,7� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 8 JURISDICTION M FACILITY 8 TANK 9 STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE I 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 REGULATIONS FORM 8 (1291) iORM$-Rt