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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B o MARK ONLY COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ° �� °• ❑ 1 NEW PERMIT ONE ITEM ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ❑ 6 TEMPORARY TANK CLOSURE ❑ 7 PERMANENTLY CLOSED ONSITE ❑ 9 TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.. C. DATE INSTALLED(MO/DAY/yEAR) 11 MANUFACTURED BY: I^ D. TANK CAPACITY IN GAL ONS: II.TANKCONTENTS IFA-11SMARKEO,COMPLETEI7EM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑❑ 2 PETROLEUM 4 OIL B p, ❑ to REGULAR ❑ 3 CHEMICAL PRODUCT ❑ e0 MPTY ❑ 1 PRODUCT UNLEADED Ian 3 DIESEL ❑ Ib PREMIUM �I 4 GASAHOL ❑ 6 AVIATIONGAS 95 UNKNOWN ❑ 2 WASTE UNLEADED D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑❑ 5 JETFUEL ❑ 7 METHANOL 2 LEADED ❑ 9B OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B,ANDC,ANDALLTHATAPPLIESINBOXDANDE C'A.S.#: A. TYPE OF ❑ 1PUUBLE WikLL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2 E WALL ❑ 1 11 4 SECONDARY -CONTAINMENT 99 OTHER 95 UNKNOWN 1 BARE STEEL (VAULTED TANK) ❑ B. TANK ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC (PLimaryTank) ❑ 8 PoLWINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 IOD% METHANOL COMPATIBLE W/FRP 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING 3 EP LINING ❑ 5 GLASS LINING El6 UNLINED ❑,_,_, / LINING ❑ 4 PHENOLIC LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANO95 UNKNOWN El99 OTHER L? YES,_ NO_ D,CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING �DIi'� PROTECTION ED CATHODIC PROTECTION ❑ 91 NONE ❑r J i 95 UNKNOWN WRQ ❑ 4 FIBERGLASS REINFORCED PLASTIC E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) ❑ 9B OTHER OVE FILL IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFRAPPIPCgB ENTION EOUIPMEN7INSTA LED(NEAR) A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE Wq(y A U 3 GRAVITY A 1 99 OTHER C. MATERIAL AND A Q I BARE STEEL A U 3 LINED TRENCH A U 95 UNKNOWN A U 2 STAINLESS STEEL A UCORROS99 OTHER PROTECTION A U 5 ALUMINUM A U 6 CONCRETE A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE PROTECTION A U 9 GALVANIifD STEEL A U 70 CATHOp10 PROTECTION 7 STEELW/COATING A U A U 95 UNKNOWN 3 IOD% METHANOL COMPATIBLE WIFRP D. LEAK DETECTION E]1 AUTOMATIC LINE LEAK DETECTOR A U 99 OTHER ❑2lINE TIGHTNESS TESTING � 3lil V.TANK LEAK DETECTION MONRDgING ❑99 OTHER ❑ I VISUAL CHECK 2 INVENTORY RECONCIlIAT10N ❑ 3 ZE MONRORING a 6 TANK TESTING ❑ 7 INTERSRTIAL MONITORING 91 NONE ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING El 95 UNKNOWN VL TANK CLOSURE INFORMATION ❑ 99 OTHER 2.ES71MATED OUANTITV OF SUBSTANCE REMAINING 3.Wq5 TANK FILLED WITH THIS FORb HAS BEEN COMPLETED UNDER PENALTY OF PERJUROF INERT MATERIAL 7 VES ❑ NO❑ APPLICANTS NAME Y,AND TO THE BEST (PRINTED A SIGNATURE) MY KNOWLEDGE, IS TRUE AND CORRECT DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW p COUNTY# JURISDICTION# 42 3.a D STATE I.D.# ® JURISDICTION [ FACILITY# 9S9 TANK#j BER Y/D PERM IT NUMd IU ATE e7 7 6 D / 7 PERMIT AppROVED BG S PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WISE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND 4rAGE TANK REGULATIONS FORM B (1291) FOROm1S-116