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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTELE I MARK ONLY i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE.[OF INFOAMATION ❑ 7 PERMANENTLY=SED ON SITE { ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK'CLOSURE ❑ 9 TANK REMOVEr7Z DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ISIS- SPECIFY IF UNKNOWN � p A. OWNER'S TANK I.D.s B. MANUFACTURED BY: y. C. DATE INSTALLED(MOlDAYnEAq) .'� � D. TANK CAPACITY IN GALLONS: II.TANKCONTENTS IFA-1 IS MARKED,COV'LETEITEM C. i. I r �1a REGULAR A 1 MOTOR VEHICLE FUEL ^_ i OIL C. � ❑ 3 DIESEL r fi AVIATION GAS UNLEADED D A GASAHOL ❑ 2 PETROLEUM p EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ : METHANOL 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE UNLEADED 5 JET FUEL E] 1_ ❑ ❑ 2 LEADED 99 OTHER (DESCRIBE N 'TnM D. BELOW) D. IF(A.1I IS NOT MARKED. ENTER NAME Or&:SS-ANCE STORED I C.A.5.6: r 111. TANK CONSTRUCTION MARKO`:=_i;_VONLY INBOXESA,B.ANDC,AND ALLTHATAPPLIES INBOXDANDE A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER I ED 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ ❑ LASS �} 4 STEEL CLAD WiFIBERGLASS;ZE�tiRCED PLASTIC � B. TANK F-11 BARE STEEL Z STAINLESS STEEL 3 FIBERG MATERIAL ❑ 5 OONCRETE 1 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM' 6 IW% METHANOL COMPATIBLE W`:P ` s IPrimeryTenkl ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER I 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING ❑ 1 RUBBER LINED �, ❑ C.INTERIOR ❑ 'i LINING5 GLASS LINING �fi UNLINED 95 UNKNOWN i 99 OTHER I C- IS LINING MATERIAL COVFAi�a.E WITH 1DDV. METHANOL? YES NO_ D.CORROSION ❑ 1 POLYETHYLENE Wq#,* . 1 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PL1.5"1G PROTECTION ❑ 5 CATHODIC PRCTEC-CS ❑ 91 NONE ❑95 UNKNOWN YYY�❑•��` 99 OTHER ,■` E.SPILL AND OVERFILL SPILL CON'TAINVcNT:%STALLED(YEAR OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) r IV.PIPING INFORMATION CIRCLE A :FABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPLIrABLE ') A. SYSTEM TYPEA 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY i ;�.A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 9S UNKNOWN A U W 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 S7EEL WICOATING I A U a 1D0% METHANOL COVPATISLE WNAP I- PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN /(I99 OTHERF-Nul i I D. LEAK DETECTION I_' 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING i 1INTERSTRIAL IMOWTORING 99 OTHER �� V.TANK LEAK DETECTION I INVENTORY R=C)OMCI_:ATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING S GROUND WAieR MONITORING ❑ 1 VISUAL CHECK ❑ 2 E ❑ ) ❑ ❑ 6 TANK TESTING 7 IN'+ERSTIT!AL MCN:"C;1NG ❑ 91 NONE ❑ 951UNKNOWN ❑ 99 OTHER ,I h ` { VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(mO,,0AYIYR) 2.E5TiV.ATED OL.ANTITY OF II 3.WAS TANK FILLED WITHNO SU'eSTANCE+'-mAiNING GALLONS ! INERT MATERIAL +? 7 t--J ❑ n THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO Tfif BEST(?f MY KNOY61LEDGE, IS TRUE AND CORRECT APPLICANTS NAME --75A7 1PRI a 5 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW; COUNTY 6 .JURISDICTION 6 FACILITY x 6 TANK o STATE I.D.# ❑ L I I I[ j PERMIT NUMBER PERMIT APPROVED BY/DATE I� PERMIT EXPIRATION DATE i I h 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 ECRM B (1281} p FORO�B•QL ' 1