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soon c STATE OF CALIFORNIA P STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <�ou o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY1 NEW PERMIT a 3 RENEWAL PERMIT K2 B. 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C OS ONE ITEM INTERIM PERMIT 4 AMENDED PERMIT C. DATE INSTALLED (MO/DAY/YEAR)ay 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV TANK CAPACITY IN GALLONS: ' ❑ 2 STAINLESS STEEL / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: MATERIAL ❑ 5 CONCRETE %) I ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER . I WIlr% IJCJVnIr 1 IVIN COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # lz B. C. [:]to REGULAR 3 DIESEL ❑ 6 AVIATION GAS B. MANUFACTURED BY: �1 PRODUCT C. DATE INSTALLED (MO/DAY/YEAR)ay -D. ❑ 2 WASTE TANK CAPACITY IN GALLONS: ' II.TANKCONTFNTS IF A_i I -C M A GKPn//IAAP I PTF ITC1Ar A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. [:]to REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT NLEADED 4 GASAHOL 1b PREMIUM❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE UNLEADED El5 JET FUEL ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # : III. TANK CONSTRUCTION MARK (INF ITFM nNI Y IN RnYFS A G ANn r ANn Al I TWAT APPI ICC IAI PnY n A- E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK F71 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS El4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING F—]4 PHENOLIC LINING C. INTERIOR �v �5 GLASS LINING [7]6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100/ METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP Ek<�FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFAROVF rROIINn OR Ll IF I wnFGn Gni INn Pnru IG APPI IrAPI C 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 0 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A (U->4 7 STEEL W/ COATING A U A U 95 UNKNOWN A U FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 TERSTITIAL AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING[:] 3 MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 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. ESTIMIT E LAST USED (MO/DAY/YR) 2. ESTIMATED OUANTITY OF SUBSTANCE REMAINING THIS FO M HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, A APPLICANTS NAME I I J E/1 / KI LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NU 3. WAS TANK FILLED WITH YES ❑ NO GALLONS INERT MATERIAL? BE M1/ K 0' (LEDGE, IS TRUE AND CORRECT 9 DATE / /-X of / 1 61-1/ BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# 'ERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DlITE / Z THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A 9ASAEN FILED FILL I HIS FOHM WO H 1 HE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGU��`N (S/! FORM B 12.91) l FOR0034B-R6