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t •e f STATE OF CALIFORNIA �+`„„• r STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °•fl.o•� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SI 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: � f I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# C. DATE INSTALLED(MO/DAWYEAR) B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: D A.aAi1 II.TANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. vV(/ A. �1 MOTOR VEHICLE FUEL ❑ 4 OIL B 1a REGULAR ❑ 2 PETROLEUM ❑ 80 EMPTY .��Ly�y+++ C. ❑ UNLEADED 3 DIESEL ❑ 6 AVIATION GAS pal 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN /❑ p WASTE UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED 2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E C.A.S.#; A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2 SINGLE WALL ❑ ❑ B5 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTEDTANK) El 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM (PrimaryTank) ❑ 9 BRONZE ❑ ❑ 6 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING `- ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING IY'6 UNLINED ll��--��"ff ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION113 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INS TALLED(MAN) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH EF APPLICABLE TION EOUIPMEN7INSTALLED YEAR) A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE B. CONSTRUCTION A A U 3 GRAVITY p U 99 OTHEq SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH C. MATERIAL AND A 1 BARE STEEL E U 95 UNKNOWN p I 99 OTHER CORROSION A 5 ALUMINUM A U 2 CONCRETE STEEL A U 3 STEELPOLYW/INYLCOATING CHLORIDE(PVC)A U 4 FIBERGLASS PIPE PROTECTION A U 8 CONCRETE A U 7 STEEL W/COgTING A U 9 GALVANIZED STEEL q U 10 CATHODIC PROTECTION A U 6 10095 METHANOL COMPATIBLE W/FRP D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR A U 95 UNKNOWN A U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORING OTHER V.TANK LEAK DETECTION ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING B TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.EST APED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF rf. SUBSTANCE REMAINING H7 GALLONS 3 WAS TAN MATERIA ITH YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 6 aIGNATBgEI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW G COUNTY# JURISDICTION# FACILITY STATE I.D.# TANK# [TPE-RM:ITNUMBER ERMIT A.P. BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS r 1 • A�i�� FOgO¢XBg6