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STATE OF CALIFORNIA e• �t• Y STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. —15 A ty MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT '�6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON _ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED•. f2lc. D I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a B. MANUFACTURED BY: sC C. DATE INSTALLED(MO/DAY/YEAR) m — — D. TANK CAPACITY IN GALLONS: D 0 ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS UNLEADED 4 GASAHOL ❑ 2 PETROLEUM ❑ 90 EMPTY t PRODUCT X1bUNLEAIDED E] 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN O 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,ANDC,AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF �1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 3>r4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE O95 UNKNOWN ='*119 OTHER 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 2 PRESSURE A U 3 GRAVITY A U N OTHER B. CONSTRUCTION A U / SINGLE WALL U DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN - A U N OTHER C. MATERIAL AND A U 1 BARE STEEL A 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U N OTHER D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR 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 GROUND WATER MONITORING ❑ 6 TANK TESTING x 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMA A AST USED(MO/DAVIV R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUB STANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLET ENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORK T .. DATE APPLICANTS NAME (PRINTED a$IGNATORE) LOCAL AGENCY USE ONL STATE I.D.NUMB UR NUMBERS BELOW COUN � RISDICTION# ACILITY# - STATE LD.# TY (p �# PERMIT—NUMBER ED BY/ TE PERMIT EXPIF9TI.jDAATE / 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 FORMS (12-91) �-� ! J ��_ !l FOROW9B-R6 �.cA'e• Gvt ('�`-yri��.ia�clCt. `� l �' � � � — Y� �-.��s