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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s• UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. y MARK ONLY IV 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TAN DBA OR FACILITY NAME WHERE TANK IS INSTALLED: t (,� ks 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN Ck l�'d A. OWNER'S TANK I.D.# O I S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 1 D. TANK CAPACITY IN GALLONS: ILTANK NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL8. C. F7la REGUL R 3 DIESEL ❑ 6 AVIATION GAS F71 PRODUCT 2 PETROLEUM ❑ 80 EMPTY ❑ lb PREMIUM 4 GASAHOL ❑ 7 METHANOL F73 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E] 2 LEADED UNLEADED JET L OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 1 G + C.A.S.# III. TANK CONSTR CTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND 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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 100% METHANOL COM ATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN V99 OTHER aW" F71 RUBBER LINED ❑ 2 ALKYD LINING n EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ =5 GLASS LINING ❑ 6 UNLINED 95 UNKNFYN 99 OTHER L IS ING MATERIAL COMPATIBLE WITH 1001/6 _METHANOL? YES_ NO (,lm .^- "y.(Y1 D.CORROSIONFV 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) lfgH kMtb O OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF A13OVE G5CYND OR U IF UNDERGROUND,80TH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A v 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 14 FIBERGLASS PIPE CORROSION A U/5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 8 100°/, METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNO N A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING 3 I AL 99 OTHER MONITORING ❑ V.TANK LEAK DETECTION FE❑ 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.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO a SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED d SIGNATURE) / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 'l, -I COUNTY# JURISDICTION# FACILITY#A4 TANK# STATE 04 ''�� S D PERMIT NUMBER PERMIT APPROVED BY/DATE PEflMIT EXPI TI N DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) 4FOR"2034 -R6