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9f STATE OF CALIFORNIA .F'� � STATE WATER RESOURCES CONTROL BOARD ��, UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ��°"� MARK ONLY 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 ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: u/, I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.* B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS: 0 C Y ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL C, �taU LFA EU ® 3 DIESEL ❑ 6 AVIATIONGAS F12 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 16 PREMIUM 4 (iA4NgL ❑ 7 METHANOL UNLEADED 6 JET FUEL F-13 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 90 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEMONLY IN BOXESA,B.AND C.AND ALLTHAT APPLIES INBOXDANDE " A. TYPE OF >LI DOABLE 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 ❑ 8 IW% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ N 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 ❑96 UNKNOWN 'YWht❑] 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)TLzz IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A V1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL Ag7 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 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 99 OTHEReUUIMvRAu D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING U.99 OTHER . J V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING�g 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 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 ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED bNDER PENALTY OF PERJURY,AND TO BEST MY KNOWLEDGE,is TRUE AND CORRECT APPLICANTS NAME OA v LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER EiCOMPOSEDOFTHE FOUR NUMBERSBELOW COUNTY# JURISDICTIONS FACILITY* TANK B O STATE I.D.# m x 131 / 8 9 fololl( PERMITNUMBER U PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 3 � THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) FOROOABRf Now v