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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s` , , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ": COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM °.,.�"...� MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 9 TEMPORARY(TANK CLOSURE ❑ B TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: YJV 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a B. MANUFACTURED BY: U C. DATE INSTALLED(MOfDAYP/EAR) D. TANK CAPACITY IN GALLONS: Q p II.TANK C TENTS IFA-11SMARKED.COMPLETEITEMC. REULARA 1 MOTOR VEHICLE FUEL E::] 4 OIL 8. C. ❑ 1aUNGEADEO 3 DIESEL E::] g py1AT10N GAS ❑ 2 PETROLEUM ❑ 90 EMPTY1 PRODUCT ❑ 1b PREMIUM a GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)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 ALLTHAT APPLIES IN BOX D AND E A. TYPE OF ❑ DQUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Tf 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (Primuy Tak) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 D LWWG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR Q 5 GLASS LINING ,L—Lf,"9/UNLINED ❑ 95 UNKNOWN a 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP n 2 ABATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION `2'9191 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U <EjaWq A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A UBARE EEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. 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 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 5 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USfD MOMAYN'R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO I?'/(gQ z- SUBSTANCE REMAINING � GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE iPRINTED 4$IDNAIDREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY JURISDICTION a FACILITY a TANK 09CR Z qi STATE LD.# ® � o 3 �G O PERMIT NUMBER PERMIT APPROVED BVD PERMIT EXPIRATION DATE Y].p Y?i FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. /