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STATE OF CALIFORNIA .. .....••..f S�� STATE WATER RESOURCES CONTROL BOARD 'a; UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B 3r . f COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PER MR 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑I 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: lraS- 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.s D B. MANUFACTURED BY: ! C. DATE INSTALLED(MO/DAY)YEAR) V I D. TANK CAPACITY IN GALLONS: 'S-jJ 0 0 II.TANK CONTENTS IFA-1 IS MARKED,COM PLETEITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OILB. C• ❑ 1a REGUL R I IESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib PREMIUM 4 GASAHOL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED UNLEADED 5 JET FUEL 7 METHANOL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A_S. Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALLTHAT APPLIES IN BOX D AND E A. TYPE OF ❑ }/RUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ED/1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100/. METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL (❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 UNLINED LINING 5 GLASS LINING ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINCORCED LAS_TIC_ PROTECTION ❑� 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN `f ❑� 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION '- A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 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 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 'MONITORING ❑!99 OTHER V.TANK LEAK DETECTION { f 1 VISUAL CHECK I__2 INVENTORY RECONCILIATION ❑ 3 VADOZE 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 SED( O/DAY/YR) ( 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH _ZZa SUBSTANCE REMAINING GALLONS I INERT MATERIAL? 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 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE 01COUNTY x JURISDICTION FACILITY x TANK x PERMIT NUMBcR ❑❑❑ Z=/' �+ I ��=PERMIT APPROVED BY/DATE PERMIT XPIRATION D TE fl4/s -- / FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A.PERMR APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN F17/Z/ FOROGNB RS