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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD .4 ^ UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B y: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `"'•�^ MARK ONLY1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE ITE ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.I B. MANUFACTURED IGLONIS V C O C. DATE INSTALLED(MOIDAYIYEAR) �9 D. TANK CAPACITY I 1 I l II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. � '-UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 90 EMPTY 1 PRODUCT 16 PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT E] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.ANDC.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B IWY. METHANOL COMPATIBLE W/FRP (PrimaryTents) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F-15 GLASS LINING EV E_—]6 UNLINED ❑ 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 ❑ 5 CATHODIC PROTECTION ❑ 91 NONE O25 UNKNOWN ❑ W OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(PEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOT14 IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U T PRESSURE A U 3 GRAVITY A U W OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)- U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 0 100% METHANOL COMPATIBLE WIFRP 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 TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAD02E MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATE R MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS IN MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND THE ESTOFMYKNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE 1PRIKTED46bNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I tb STATE I.D.# COUNTY 9 JURISDICTION w FACILITY r 00399 TANK M 00 49 m 13a5 50 ga. 43 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION 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 FORMS (1291) F0IMH9Ia