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I �Fv STATEOFCAUFDRIAA 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 ❑ 2 RENEWAL PERMIT ❑ 5 CHANGE OF NFORMATCN O 7 PERMANENTLY CLOSED ONSITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 6 TANK REMOVE`. DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL r,'EMS- SPECIFY IF UNKNOWN A.OWNER'S TANK L D.• S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) L9 C,, D. TANK CAPACITY IN GALLONS:5, O ILTANKCONTENTS WAIS MARKE:.O'WP_ETe ITEM C. 7 A �1 MOTOR VEHICLE FUEL 4 OIL B. O. ❑ 1AUNLEREGA ED 3 DIESEL ❑ F AS'uiX3N GAS r72 PETROLEUM W EMPTY T PRODUCT ❑ t9PREMIUM 4 WSAHOL ❑ - WE-HANOL UNLEADED 8 5 JET FUEL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE N -M D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAMED SJBPS-ANCE STORED C.A.S.•: r III. TANK CONSTRUCTION MARKDNE-V ONLY IN BOXES A.B.AND C.AND ALLTNAT APPLES NBOXDANDE A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 25 UNKNOWN SYSTEM ❑ 2 SINGLE WALL _I 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS '.IS? 4 STEELCLAD W:FIBERGLASS R-EN=CRCEDPLASTC MATERIAL ❑ 5 CONCRETE _� 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 6' 100t4 METHANOL CAMPATISLE W=RE (PrimaryTank) ❑ 2 BRONZE 10 GALVANIZED S—e EL ❑ PS UNKNOWN ❑ 99 OTHER 1 RUBSER LINED —! 2 ALKYD LINING ❑ 3 EPDXY LINING O 4 PHENOLIC LINING C.INTERIOR ❑ S LASS LINING -6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERAL COMEA-E_E W,-,N 100% MET14N'OL7 YES_ NO_ D.CORROSION I 1 POL ETHYLENE W.D.° 2 WA7NG ❑ 7 VINYL WRAP I A FIBERGLASS REINFORCED P'.A5`C PROTECTION n 5 CATHODIC PRO:--EC-ON 91 NONE G65 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTANIVEVC;NS-A.LED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR IV.PIPING INFORMATION CIRCLE A =AEO:EG:OJNDORUIF L''•:�EaGAOU'.7.BOTH IFAPPLCABLE I A. SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 8. CONSTRUCTION A U I SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 C.'HER C. MATERIAL AND A U I 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 6 100% METHANOL COUZAT NILE WARP PROTECTION A U 9 GALVANMO STEEL A U 10 CATHODICPROTECTCN A U 95 UNKNOWN A Q� p OTHER �II OF'L•'IaSC D. LEAK DETECTION AUTOMATIC LINZ LEAK DETECTOR ❑ 2 LINES 7GHTNESS TES71NG � ' MJtfOR;NG 99 OTHER—a— V.TANK LEAK DETECTION 1 VISUAL CHECK CI 2 INVENTORY RECONCILIATION ❑ 3 VAOCZE MONITORING>rI A AUTOMATIC TANK GAUGING ❑ 5 GROUND WA%ER MO417ORING 6 TANK T-EESTING Z 7 INTERSTITIAL VCNITCRIN'G ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(VOT)AY.YR) 2.ESTIMA7EDOUAN'71TYOF 3.WAS TANK FILED W'7 S 40 II SUBSTANCE REVD." GALLONS I INERT MATER.aL• N �— THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND V HE BEST4F MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME N, DATE pw a s 4ru I /.t/iy l 1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY TANK# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY DATE PERMIT EXPIRATION DATE 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 .ORM 2 02-91) roExvEw