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STATE OF CAUFOR)M ; .�1•"": , STATE WATER RESOURCES CONTROL BOARD U DERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR TALC SYSTEM. MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON S ONE REM 2 MITERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ a TANK DBA OR FACILITY NAME WHERE TANK IS NSTALLED: L� I. TANK DESCRIPTION comm-ETE ALL ITEMS-sPECIFY IF uwNowN A. OWNER'S TANK I.D.s �3 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) r!�� I 0. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 ISMARKEO.COMPLETEITEM C. —1 ,a REGULAR 3 DIESEL A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ UNLEADED LL a GASg1gL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 90 EMPTY ❑ 1 PRODUCT ❑ ibPREMIUMUNILEADE0 I�Jt S JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT Q 96 Umomm ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BQOw) 0. F(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED G A.S.a: 111. TANK CONSTRUCTION MARK ONE REM ONLY N BOXES A.B.AND C,AND ALL THAT APPLES N BOX 0 AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 L*0040 N SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL Ci 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAO WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE Q 6 POLYVINYL CH LORIIOE Q 7 ALUMINUM ❑ MI IW% MEI.W90L COMPATIBLE W1FR P (PdawYTar*) CI 9 BRONZE Q 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ N OTHER Q 1 RUS�R LINE Q 2 ALKYO LINING Q 3 EPDXY UNNG Q A PHENOLIC LINNG- C.INTERIOR ❑ S GLASS LINING ❑ 6 UNLINED Q 96 UNKNOWN ❑ N OTHER LINING IS UNNG MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP Q 2 COATING Q 3 VWYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ s cATHoDIc PROTECTION Q 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL.AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT WSTALLEO(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNOERGROUNO,BOTH F APPUCASLE 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 90 OTHER C. MATERIAL AND A U t STEEL A U 2 STAINLESS S[E U 3 POLYVINYL 04LORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U s UNANUAiM A U 6 CONCRETE A U 7 STEEL YIN COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A U 10 CA ROTECTION A U 96 UWNOWN A U 99 OTHER D. LEAK DETECTION T AUTOMATIC UNE LEAK DETECTOR 2 UNE TGWrNESS TESTiIq ❑ MOMNfORIlIG ❑ OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VA002E MONITORING Q a AUTOMATIC TANK GAUGING Q LINO WATER MONITORING 6 TANK TESTING Q 7 INTERSTRNLMONRgRNG Q 91 NONE ❑ 93 UNKNOWN VI.TANK CLOSURE INFORMATION I_ESTIMATED DATE LAST USED(MOA)AY/YR) Z.ESTIMATED OUANTTTY OF 3.WAS TANK FILLED WITH SI BSTANCEREMANING GALLONS I ItERTMATERIAL? YES Q NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANrs NAME (pRwm♦slf"u m DATE —s LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LD.# COUNTY x JURISDICTION K FACILITY S TANK# Z PERMIT NUMBER PERMIT APPROVED 8Y/OATE PERMIT EXPIRATION DATE FORM 9(7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.