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! • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 2 n 6 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 ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT LD4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED (, , DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMSSPECIFYIF UNKNOWN A. OWNER'S TANK I.D.# (,r, B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAfl) / (, ".�i 0. TANK CAPACITY IN GALLONS: ? ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. 1a REGULAR 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED 4 GASAHOL O 1 PRDOUCT ❑ 1bUNLEAIO D ❑ 5 JETFUEL7 METHANOL 2 PETROLEUM 0a EMPTY3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WA ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BO%D ANDE ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN A. TYPE OF SYSTEM F_] 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ s CONCRETE (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑95 UNKNOWN O 99 OTHER gt NONE PROTECTION ❑ 5 CATHODIC PROTECTION ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 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 RETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP CORROSION A U 5 ALUMINUM A U B CONIC 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 ❑ IG 2 LINE TIGHTNESS TESTING ❑ 3 MONRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.EST179D DATE LAST USED(MO/DAY/VR) ❑2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO 1 SUBSTANCE REMAINING _ GALLONS INERT MATERIAL ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION It �FACIL�I�TY#��_�� L_�I-J--JL—t>�'-i TA STATE I.D.# m V PERMIT APPROBY/DATE PERMIT E%PIRATtol ATE ? , PERMITNUMBER s `;P "kt- THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT rUHMT HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS _. FORM B (1291) 0 _