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STATE OF CALIFORNIA �" '""" +, STATE WATER RESOURCES CONTROL BOARD J UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ° �� °° ° w° F`a I . °i COMPLETE A SEPARATE FORM FOy H TANK SYSTEM, c""'°""�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1pfS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ S TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I Z) 4 I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# O% _ B. MANUFACTURED BY: C. DATE INSTALLED (MOIDAY/YEAR)c� D. TANK CAPACITY IN GALLONS: V� IL TANKrANTPNTS Ice_ncueRvcr,1�uolcTCITc11 A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1eUNLEADED REGULAR 8 3 DIESEL Lr a AVIATION CAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL E]7 METHANOL [--]3 CHEMICAL PRODUCT ❑ 95 UNIWOWN ❑ 2 WASTE ❑ UNLEADED 2 LEADED 5 JET FUEL g (PdmaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 ALKYD LINING EPDXY LINING C. A. S. * : III. TANK CONSTRMf TIt)N M.Blr nuc lTcu nul vlu Rnvicee o A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS IV4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER PIPE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNO 99 ❑ OTHER LINIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NOJ� GALVANIZED STEEL D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP y 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑96 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EOUIPMENTINST:ZLED(YEAn IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND_ BOTH IFAPPI ICARI F A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U / SINGLE WALL A DOUBLE WALL A U 3 LVED TRENCH A U 06 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 0FIBERGLASS 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 GALVANIZED STEEL A U 10 CATH PROTECTK)N A U 95 UNKNO A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 8I I PAL [_]9B OTHER MONITORING I. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAD07E MONITORING FV 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED(MO/DAY/YR) 2. ESTIMATED OUANTITY OF 3. WASTANK FILLED WITH SUBSTANCE REMAINING GALLONS IN MATERIAL? YES E:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNITY# JURISDICTION#_0 FACILITY# TANK# STATE I.D.# 1() 6 3 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. 1 7� f ILC InW TVnm°YIIn in.LVVML M..nLI 1mrLCmcmiin" inc uNuamumuu w DiumAUC iAnK RCUULRIIVNJ ��\\\\l -rte FORMS (12-91) FOROmIBR6 I3 a