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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD b UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B e ai COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT C 3 RENEWAL PERMIT ❑ S CHANGE OF INFORMATION �❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT C A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE IXI B TANK REMOVE. DBA OR FACILITY NAME WHERE TANK IS INSTALLED: lc- I. TANK DESCRIPTION COMPLETE Al rMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.• B. MANUFACTURED BY: C. DATE INSTALLED(MODAYIYEAR) 1 D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA•11SMARIC -LfTEREMC. ED3 DIESEL 1 MOTOR VEHICLE FUEL t OIL B. C. ❑ 1AUNLEAD-eD A GASAHOL C E AVIATION GAS 2 PETROLEUM LO EMPTY 1 PRODUCT ❑ 1b PREMIUM C T V--,HANOI _ UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE 1N f-M D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME O S:S57ANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ISM ONLY IN BOXES A.B.ANDC.AND ALLTHAT APPLES INBOX D AND A. TYPE OF ❑I 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 96 UNKNOWN SYSTEM L� 2 SINGLE WALL J A SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 BARE STEEL 'CI 2 STAINLESS STEEL '�3 FIBERGLASS ❑ A STEELCLAD WI FIBERGLASS REN=.RCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B t00x METHANOL COMPATIBLE W'=+? (PrimAryTAN) ❑ 9 BRONZE I 1D GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL CDV-ATGS c WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETWYLENE WRAP 1 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTC PROTECTION ❑ 5 CATHODIC PRC-=C-CN ❑ 91 NONE ?1—PS UNKNOWN ❑ 99 OTHER - E.SPILL AND OVERFILL SPILL CONTANMENT!NS-,ALLED(YEAR) ^'' OVERFILL PREVENTION EOUIPMENT INSTALLED(YEA IV.PIPING INFORMATION CIRC'SAI-ABCVEGROUNDORUIFUNDERGROUND.BOTHIFAPPLCABLE A. SYSTEM TYPE A Orl SUCTO% A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER AA. B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN A U W OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U K FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U 6 100% METHANOL OOMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AS�95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC UNE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MDNOORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILMTION ❑ 3 VADCZEMONITORING I A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITALMCN:TORNG ❑ 91 NONE ('D 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTWATED DATE LAST UIDAYNA) 2.ESTIMATED OJA%'TITY OFI 3.WAS TANK FILLED WITH YES iJ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL? r THIS FORM HAS BEEN COMPLETED UNCER PENALTY OF PERJURY,AND TO THE 0 qST OF My KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME N DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY E JURISDICTION 6 FACILITY 6 TANK 6 STATE I.D.# m y.' PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE -.. THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS �, FORM 11291) F0F ;4