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1` N v STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDr UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY 0 1 NEW PERMIT ONE 3 R ONE REM ❑ RENEWAL PERMIT 5 CHANGE OF INFORMATION 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 7 PERMANENTLY ❑ e TEMPORARY TANK CLOSURE TE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ❑ 8 TANK REMOVED S 3S /ZC I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# ,O- C. If DATE INSTALLED(MO/DAYryEAR) B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: ,.,n, II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. (/ v A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL / ❑ 2 PETROLEUM B I-�/ C' ❑ UNLEADED 101 3 DIESEL ❑ 6 AVIATION GAS ❑ BO EMPTY LLL"'JJJ 1 PRODUCT 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 1b PREMIUM ❑ 95 UNKNOWN ❑ 2 Wpg� UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARKONE ITEM ONLY IN SOXESA,B.ANDC,ANDALL THAT APPLIES INBOXD AND E C A.S.#: A. TYPE OF El WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2 SINGLE ❑WALL 4 [:] 95 UNKNOWN SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL 11 5 CONCRETE ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ (PrimaryTank) 6 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ 9 BRONZE F-18 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 1 RUBBER LINED El 99 OTHER C.INTERIOR ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING LINING ❑ 5 GLASS LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100°6 METHANOL? ❑ 99 OTHER D.CORROSION El VES_ NO_ I POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 5 ❑ 3 INVL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CATHODIC PROTECTION ❑ 91 NONE 6 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) RFILL IV.PIPING INFORMATION CIRCLE IFABOVE GROUND OR U IF UNDERGROUND,BOTH EF APPLICABLE TON EQUIPMENT INSTALLED YEAR) A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE B. CONSTRUCTION A A U 3 GRAVITY A U 99 OTHER 1 SINGLE WALL A U_2DOUBLE WALL p U 3 LINED TRENCH C. MATERIAL AND A U 1 BARE STEEL A U 95 UNKNOWN p U 99 OTHER A U 2 STAINLESS S CORROSION A U 5 ALUMINUM TEE' A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBER A U 8 CONCRETE PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC P OTECTION 7 STEEL W/COATING A U GLASS PIPE S 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION / AUTOMATIC LINE LEAK DE7ECTOfl Am®UNKNOWN A U 99 OTHER 2 LINE TIGHTNESS TESTING � 3 �-� V.TANK LEAK DETECTION MONROgING ❑ 99 OTHER_ ❑ 1�lYSUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LASTUSEO(MO/OAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING GALLONS 3 WASNERT MATERIATANK FILLED WIIH YES THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AN❑D CORRECT APPLICANT'S NAME (PRINTED a SIGNATURE( DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ,a\� COUNTY# JURISDICTION# FACILITY# STATE I.D.# ® TANK# PERMITNUMBER 'f��l •7 �/ 6 0 PERMIT APPROVED BV/DATE PERMIT EXPIggTI N,[jATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMS (1291) FILE THIS FORM WITH T�CAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR09