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ti PN0 �..4 Cpl' STATE OF CALIFORNIA t STATE WATER RESOURCES CONTROL BOARDJw 00 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 ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 10 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) rl nou D. TANK CAPACITY IN GALLONS: II.TANK NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. liv1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ 1aREGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM O 80 EMPTY 1 PRODUCT ❑ lb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT F—] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW), D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.A III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF v 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK F-11 BARE STEEL ❑ 2 STAINLESS STEEL F--] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100°/ METHANOL CO PATI LE W/FRP,�e (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN V99 OTHER Y 19i F—] 1 RUBBER LINED ❑ 2 ALKYD LINING V95 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR r---1 5 GLASS LINING ❑ 6 UNLINED UNKNOW ❑ 99 OTHER LINING LI 'I IS ING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO U/nt4"-V,Y► D.CORROSION EV 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER 44 ov.- -- I!— . -^.. w E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) lq4 V RFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVE G ND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 P§NOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)At/ HLORIDE(PVC)AU 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COAT IN A U 8 100°/ METHANOL COMPATIBLE W/FRP PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A (J 95 UNKNO N A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR FINTERSTITIAL2 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 ul 7 INTERSTITIAL MONITORING 17 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 ❑ 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FA ILITY#-R 80 TANK# STATE I.D.# = 114 PERMIT NUMBER PERMIT APPROVED BY/DATE PEWIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. a FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) < FORD R6