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STATE OF CALWORNLA .•a "" STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMITRENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE )TEM 0 2 INTERIM PERMIT 51-11 AMENDED PERMIT 0 $ TEMPORARY TANK CLOSURE ❑ e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED, I. TANK DESCRIPTION cOMPLETEALLrrEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.4 E MANVFAG RJRED BY: G DATE 1NSTALLE0(MQ�OAYIYEAA) o, b` Lia D. TANK CAPACITY IN GALLONS: Lo)000 II.WANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C, A, i MOTOR VEHICLE FUEL Z.4 OIL g. C, 1t PEGULAA UNLFJDED 9 DIESEL 5 AVIATIONG.AS Z PVAOLEUM 60 EMPTY PRODUCT Sm PREMIUM UNLEJIDED A GASOHOL 7 MMANOL fe MWADE URSAOED JETFUEL B MM a GHE741CAL pROOUtT 0.5 UNKNOWN Q 2 WASTE 2 LEADED &pq OTHF3I pEscRIBE pi rrEm o.ma ow) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S,R III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,13,AND C,AND ALL THAT APPLIIES IN BOX 17 AND E If A TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 NTM4kL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM Q 2 SINGLS WALL 1 SINGLE WALL IN A VAULT 1:1 99 OTHER B. TANK Ej I BARE STEEL 2 Z17AIlLESS STEEL 3 FIBERGLASS [�:) A STEEL CLAD W/FIBFAGLASS REINFORCED PLASTIC MATERIAL Q 5 CONCRETE e POLYVINYL CHLORIDE 7 ALUMINUM 0 B 100% METHANOL COMPATIBLE W/FRP (PTfnlAlry T61k) a p BRONZE 10 GALVANIZED STEEL 25 UNKNOWN 99 OTHER C.INTEREOR ❑ 1 RUBBER UNED 2 ALKYD UNNG a 3 EPDXY LINING � A PHENOLIC LINING LINING OR 5 OLASS UMNO e UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR I POLYETHYLENE WRAP 2 COATING 3,VINYL WRAP A FIBERGLASS REINFORCER PLASTIC CORROSION 91 NONE 83 UNKNOWN 99 OTHER PROTECTION ❑ s cATHoOIc PROTECTION Q [� 0 E.SPILL AND OVI=AFILL,MSPILL.CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) CROP T1JBE YES NO STRIKER PLATE YES NO DE5PfNfiER CONTAINIV YEb NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH 1F APPLICABLE A. SYSMM TYPE A@ 1 SUCTION A U 2 PAESSURE A U 3 GRAVITY A U A FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AQ I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 45 UNKNOWN A U F9 OTHER C. MATERL4L AND A U I RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A A F113CROLASS PIPE CORROSION A U E ALUMINUM A U H CONCRETE A U T STEEL WI CCATING A U 0 100:4 METHANOL COMPATIBLE W+FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 93 UNKNOWN A U w OTHER D. LEAK DETECTION 01 urc'a 2 . uRKTC. ❑I artl.WM14MUL A,,UM mncOED 9e on+eR V.TANK LEAK DETECTION 1 VISUAL CHECK 2 MANRREIDONCI ENTE 3 MONOZE CrOAING + GAUGING C TANK D.C MONITORING OUND WATER 6 ANNUAL TESiINGTANK 7MONTTORQNGTER INSTITIAL A SIR � 9 WEEKLY MANUAL 10 MMONTHOLY TANK 95 UNKNOWN 99 OTHER VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE N-PLACE) 1,E9"IIMATED DATE LAST USED IMOIDAYNFO 2,ESTIMATED OUANTITY OF 3.WAS TANK RL L FD WITH SUBVANCfi REMAINING GALLONS INERT MATERIAL 7 YES NO THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND BOAREICT TANK OWNER'S NAME / DATE (PRINTR &S;WATUFM LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY f JURISD=CN A FACILPTY R TANK 0 STATE I.D:# Ll I 1 11 - i I PERMIT NUMBER PERMIT APPROVED BWDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FOMM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST Be COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLtMEH LNG THE UNDERGROUND STORAGE TANK REGULATIONS Fcmm