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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 SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE q 8 TANK REMOVED —7 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: i '' 1 ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) . i MI`4r% ur-ov nir I I MY GUMPLE I _ ALL ITEMS -- SPECIFY IF UNKNOWN l A. OWNER'S TANK I. D. #B. MANUFACTURED BY: l J 1 m1 `C 1 C. DATE INSTALLED (MO/DAY/YEAR) ; D. TANK CAPACITY IN GALLONS: S �_O^ ,5 h, II. TANK CONTENTS IFA-11RMARKpnr.r1MRIFTFITGMr 1 MOTOR VEHICLE FUEL ❑ 4 OIL A' B. C 1—! to REGULAR ❑ 3 DIESEL L—J UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT F—]95 UNKNOWN ❑ 2 WASTE E:]2 LEADED �99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. s: III. TANK CONSTRUCTION MARK nNF ITEM r1NI Y IN Rr1YGS A R ANn r ANn Al 1 TWAT ADDI ICc IAI DnV n A— C 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 1 BARE STEEL F--]2 STAINLESS STEEL F73 FIBERGLASS ❑ 4 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 ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F—]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING El6 UNLINED 21,95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR)A IL (.' LQ OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) UNKAk W IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. ROTH IF APPI ICARI F A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A�U:' 3 GRAVITYA 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 CORROSION PROTECTION A U 1 BARE STEEL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 6 CONCRETE A U 7 STEEL W/COATING A U 95 UNKNOWN A U 10 CATHODIC PROTECTION ALU) 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING3 I ERSTI AL MONFORING — 0 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 E: J5 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUB STANCE REMAINING GALLONS NERTMATERIAL? YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE, SES1.OF MY` N qC DGE, IS TRUE AND CORRECT APPLICANTS NAME a �" DATE (PRINTED 8 SIGNATURE) Vim c . U. LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# q 12 Is 1 J_tEUD�----- 'ERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A. UNLESS A CURRENT FORM A HAS 13FFN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) FOR0034B-R6 tux.