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•� STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. [UDIIA RK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT NE ITEM ❑ 2 INTERIM PERMIT O ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED OR FACILITY NAME WHERE TANK IS INSTALLED: / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# "J " �i� B. MANUFACTURED BY: 1 C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPpCITV IN GALLONS: /� /)/�/I ILTANKCONTENTS FA-1 IS MARKED,COMPLETE ITEM C. ( (lCJ A. 7(A.1) MOTOR VEHICLE FUEL ❑ 4 OIL g 1a REGULAR PETROLEUM 80 EMPTY C. ❑ UNLEADED 3 DIESEL ❑ 6 AVIATION GAS CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTCT1b PRE ❑ 4 GASAHOLUNLEgOED 5 JET FUEL ❑ 7 METHANOL OTHER (DESCRIBE IN ITEM D. BELOW) D. NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C.AND ALL THAT APPLIES IN BOX D AND [SYSTEM YPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER r2 SINGLE WALL ❑ ❑ 95 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER TANK 1BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC maryTAAk) ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OOTHEgETHANOL COMPATIBLE W/FRP 9 BRONZE ❑ ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C.INTERIOR ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING '�6 UNLINED ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? 99 OTHER 95 UNKNOWN VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 3 VINYL WRAP ❑ q.FIB 5 CATHODIC PROTECTION 91 NONE g5 UNKNOWN ERGLASS REINFORCED PLASTIC ❑ ❑ [:] 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE ) fD. 7LEAK TYPE 1 SUCTION A U 2 PRESSURE UCTION A U A U 3 GRAVITY A U 99 OTHER SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH L AND A I BARE STEEL A U 95 UNKNOWN p U 99 OTHER A U 2 STAINLESS STEEL p U 3 POLWINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE SION A U S ALUMINUM A U B CONCRETE TION A U 9 GALVANIZED STEEL I U 7 STEEL 5 COATING A U B 100% METHANOL COMPATIBLE WIFRP A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER TECTION ❑ 1 AUTOMA7IC LINE LEAKDETECTOR ❑ 2 LINE TIGHTNESS TESTING �— 3 S V.TANK LEAK DETECTION MONITORING 99 OTHER ❑❑ T VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WA�MONITogN, 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMAT D=T LAST USE MOD ,, 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER"PENALTY OF NAME PERJURY,AND TO THE BEST OF MY APPLICANTS KNOWLEDGE, IS TRUE AND CORRECT (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOZFORM rrl, I l COUNTY# JURISDICTION# FACILITY# STATE I.D.# m �m TNK# PERMIT NUMBER PTE TION•FORMA,UNLESS A CURRENT A FILE THIS FORM WHAS BEEN FILED. FORMS (1WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 291)