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,1 I ydd4 �y f�' C P �1 STATE OF CALIFORNIA ^` � o STATE WATER RESOURCES CONTROL BOARD W. ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. EMARKLY 11 NEVJ PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE M ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY NAME WHERE TANK IS INSTALLED: (a Nj) S I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. Z B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: jM:5S IFA-1 IS MARKED,COMPLETE ITEM C. 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS VEHICLE FUEL ❑ 4 OIL B. C 0 UNLEADED f— 4 GASAHOL�q 7 METHANOLLEUM ❑ 89 EMPTY 1 PRODUCT 1bUNLAIDE ❑ 5 JET FUELAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCR18E IN ITEM Q- BELOW)RKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E rEDOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN ❑ 99 OTHER 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW1 FIBERGLASS REINFORCED PLASTIC�I 6 pOLYV1NYL CHLORIDE ❑ 7 ALUMINUM X8 100% METHANOL COMPATIBLEWIFRP❑ 5 CONCRETE L Jl ❑� 9 BRONZE10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING " \ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER O—❑ 1ES LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— L] , POLYETHYLENE WRAP [7] 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑95 UNKNOWN � 99 OTHER PROTECTION F] 5 CATHODIC PROTECTION ❑ 91 NONE ` E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALk-ED(YEAR) 19 9 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND_OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION ACV-2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL Atn2 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W!COATING A`P4 190% METHANOL COMPATIBLE WIFRP 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 ❑ 3 MONITORING 99❑ OTHER V.TANK LEAK DETECTION ❑ ❑ MONITORING 4 AUTOMATIC TANK GAUGING ❑� 5 GROUND WATER MONITORING ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VL TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO ❑ 1.ESTIMATED DAT L T USED(MO/DAY/YR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANC!CORRECT DATE ✓/ F(PR PLICANTS NAMEINTEDB LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m ❑ EL:F-= .� PERMIT NUMBER PERMIT APPROVED BYIOATE 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 REGULATIONS FOR8614&R6 FORM B (12-91)