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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ;i: . COMP'LEETi E A SEPARATE FORM r'OR E!,CWTANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 •x"-NEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ + AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 13"S DBA OR FACILITY NAME WHERE TANK IS INSTALLED: , 1 FY �/ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECFY IF UNKNOWN 33� A. OWNER'S TANK I.D.s B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED.CO L£7E�+- C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ la REGULAR El 3 DIESEL 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMIrY j'2/WASTE ROOUCT ❑ Ib PREMIUM 4 F7 V JET FUEL ❑ 7 METHANOL ❑ ❑ ❑ 2 LEADED UNLEADED L l.d g JET IN ITEM 0.BELOW) 3 CHEMICAL PRODUCT 95 UNKVC;WN 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY 1N soXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 A TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOW ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 XY LINING ❑ 4 PHENOLIC UNING C.INTERIOR ❑ 5 GLASS LINING ❑ 5 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE Wri 100%METHANOL? YES D.CORROSION ❑ 1 POLYETHYLENE WRAP E] 2 COATING ❑ 3 NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION r 191 NONE 95 UNKNOWN ❑ 99 OTHER PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE 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 U 2 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 CHLORICE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100%METHANOL COMPATIBLE W/FRP At. A U 9 GALVANIZED STEEL A U 10 CATHO01C PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC UNE LEAK DETECTOR ❑ 2 UNE TIGHTNESS TESTING ❑ 3 VONITORING ❑99 OTHER V.TANK LEAK DETECTION I❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONC:UATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) ZBSTANC ATED OUANATIT OF GALLONS i 3.WAS TAN FILLED l?H YES F-1NOC:] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME / /) �� ` PATE (PWNTE06SIGNATURE) G# /✓1 fl ql Y�p LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COU x JURISOICTIQNx FACILtfY TANK x STATE 04 1LE24 b EII) 1!�d '401 If)L)0 Wl ' i PERMIT NUMBER 1,4PERI611T APPROVED EVYIOATE I PERMIT EXPIRATION DATE FORM 13 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. qq FOR00Sf•8•Ni4