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Rt STATE OF CALIFORNIA i STATE WATER RESOURCES CONTROL BOARD s` ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B n�� C� COMPLETE A SEPARATE FORM FOR EAANK SYSTEM. �. . C�l1�OPN�� ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT s CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS D ON SITE MARK ONLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 37 r77i P I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. B. MANUFACTURED BY: U/c C. DATE INSTALLED(MO/DAYIYEAR) v{ G D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IFA-1 IS MARKED, TEM C. REGULAR A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. �1 ,,,,��// C. ❑ 18UNLEAD E ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ ASAHOL 2 PETROLEUM ❑ BO EMPTY 1 pVDUCT ❑ lbPREMIUM ❑ 5 GETFUEL ❑ 7 METHANOL 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 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.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 UBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYST EZ2 4146LE 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 s corvcRErE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP ❑ (Pflmary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR [:] s GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION F—] 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPEA U 1 sucnoN A U 2 PRESSURE A 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 CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION F-11 AUTOMATIC LINE LEAK DETE('T'1R ❑ 2 LINE TIGHTNESS TESTING L: 0 MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION it FACILITY# TANK# U IJIOA>Y3 STATE I.D.# PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT E%PIRATION DATE FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FOR901CB-RA � A-� I /