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H,uA -es STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD sr r UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� 1 a CO LETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT EV3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED s1ONSITE ONE ITEM F72 INTERIM PERMIT E:4 AMENDED PERMIT E]C)/ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED �/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' — I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D,# DOUBLE WALL V2, 3 SINGLE WALL WITH EXTERIOR LINER ❑95 UNKNOWN B. MANUFACTURED BY: C. DATE INSTALLED (MOIDAYNEAR) ' ❑ 99 OTHER B. TANK D. TANK CAPACITY IN GALLONS: II.TANKC TENTS IFA -1 IS MARKED, COMPLETE ITEM C. iuf A EV MOTOR VEHICLE FUEL E 4 OIL 8. C• la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT 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 &W" - 15r/?" /—/ —7 2 C. A. S. # 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF DOUBLE WALL V2, 3 SINGLE WALL WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM INGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10(r% METHANOL COMPATIBLE WIFRP IPrimaryTank) 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ EPDXY LINING ❑ 4 PHENOLIC LINING C.I LIIJINIGNTEROR F-]5 GLASS LINING ❑ 6 UNLINED 95 UNKNO❑'04 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100/ METHANOL? YES_ NOV 4"t4", �Iv � D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EOUIPMFNT w9TAi I Fn rvcAo, IV, PIPING INFORMATION CIRCLE A IF ABOVE GR ND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 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 STEEL Wd COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION AU GALVANIZED STEEL A U 10 CATHOD PROTECTION _ A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION LV1 AUTOMATIC LINE LEAK DETECTOR Ly 2 LINE TIGHTNESS TESTING 3 IAC OTRING 71 gg OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TfANj�J AU�ING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE E]95 UNKNOWN (Glr�o9P ❑ 99 OTHER VI, TANK CLOSURE INFORMATION I. ESTIMATED DATE LAST USED (MO,'CAYIYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ 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 # FACILITY # TANK # STATE I.D.# = D p03 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATIONDATF FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. • FOP