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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;y" v o UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B `a, � ; COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION I B TANK REMOVED MARK ONLY I NEW PERMIT ❑ 6 TEMPORARY TANK CLOSURE ONE REM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: >�• tel" I. TANK DESCRIPTION COMPLETE ALL ITEM11 . 11 IFY IF UNKNOWN S MANUFACTURED BY: G(/ U A. OWNERS TANK I.D.s D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOOAYNEAR) ILTANKCONTENTS IFA-11S MARKEO,COMPLETE ITEM C. to REGULAR 3 DIESEL ❑ 6 AVIATXONGAS LDI'F 1 MOTOR VEHICLE FUEL - 4 OIL B. C. ❑ UNLEADED 4 GASAHOL 7 METHANOL 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1bUNLEADED ❑ 5 JETFUEL3 CHEMICAL PRODUCT PREMIUM 95 UNKNOWN �2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW)1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED S to r f D.A.B. p III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C.AND ALL THAT APPLIES IN BOX D AND [:] 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ W OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F--] ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FFIP MATERIAL ❑ 5 CONCRETE (PAmaryTulk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER O I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED E:] 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION ❑ 91 NONE ❑96 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.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 CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESSTESTING ❑ MpryRORING 99 OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING ❑ 6 TANK TESTING O 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN � 9B OTHER /`y R fIJ U 4, 1 V VI.TANK CLOSURE INFORMATION J 1.ESTIM TED DAT T ED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF "� � 3.WAS TANK FILLED WITH SUBSTANCE REMAINING _ (G/ & GALLONS INERTMATERIAL7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED A SIGNATORE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ec: 1 3 l 83 Co COUNTY#'ay JURISDICTION FACILITY# TANK# STATE I.D.# 111E= wzy7o *6 PERMIT 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 BEEN FILED. FORM (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR00916R6