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iSPATE OF CALIFORNIA �� 9 STATE WATER RESOURCES CONTROL BOARD i ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B w �� I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.III rl B. MANUFACTURED BY:I lli C. DATE INSTALLED(MO/DA'YJ/YEAR) D. TANK CAPACITY IN GALLONS: wo II_TANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL 1.vmrc� m A ecrwn,. i e rvmn rvn cn�n i nnn e w i cni. C. ❑ 1a REGULAR MARK ONLY F0 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED rn l / DBAOR FACILITY NAME WHERE TANK IS INSTALLED: Zazs C C)UATT12y rl I?, ST" 5 JETFUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.III rl B. MANUFACTURED BY:I lli C. DATE INSTALLED(MO/DA'YJ/YEAR) D. TANK CAPACITY IN GALLONS: wo II_TANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR ❑ 95 UNKNOWN 3 DIESEL ❑ 6 AVIATIONGAS 4 GASAHOL ❑ 2 PETROLEUM E] 80 EMPTY Eo PRODUCT PREMIUM B. CONSTRUCTION U 1 SINGLE WALL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 2 LEADED ❑ ❑ 5 JETFUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (AA) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B. AND C. AND ALL THAT APPLIES IN BOXD A. TYPE OF ❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM a 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP (PrimuyTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER 6 CONCRETE A U 7 STEEL W/ COATING ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. IN GR ❑ 6 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LININNING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVENDOR U IF UNDERGROUND, BOTH IF APPLICABLE F3- q = A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AV BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION yj 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONrrSoTg ❑ 99 OTHER V. TANK I FAK DFTFCTION ❑ i VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 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 INERTMATERIAL7 THIS =ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND COF APPLICANTS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW FORM B (9.901 STATE I.D.# COUNTY# JURISDICTION# F3- q = PERMIT APPROVED BY/DATE ■■nn■■ ■■iii■■ renmll enrIMAHUN UAIG THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 0 • ECT