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STAR OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD +` UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION PERMAN Y CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSU E TANK RE OVER O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �. SW, I7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: �V G C. DATE INSTALLED O/DAYNEAR) D. TANK CAPACITY IN GALLONS: S II.TANK C TENTS IFA-11SMARKED,COMPLETE ITEM C. A / MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ W EMPTY 1 PRODUCT ❑ 1b PR�1IUM 4 GASNOL ❑ 7 METHANOL LEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT �95 UNKNOWN ❑ 2 WASTE I,�/¢ LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.`3 0-�LC.A.S.*: III. TANK CONSTRUCTION MARKONEITEMONLYINBOXESA,B,ANDC,ANDALLTHATAPPLIESINBOXDANDE A. TYPE OF ❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM � Z SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL lf+7 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmmyTAOk) ❑ 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 E�f-T UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE �KNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) �� r IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A&)1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A® 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 S�TEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTON i-U%95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INIMbill AL MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONEUNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DA IAST USE[CAY/YR) 2SUBI STANCE REMAMATED ITY NING NGF O GALLONS 3.WAS INERTMATERIAL? YES ❑ NOE— THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS N ME =REGULAT * (PRINTED 8 SIGNM LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#STATE I.D.#PERMITNUMBER tv( V ERT R V BY/DATE PERM EXPIRTHIS FORM MUST BE ACCOMPANIED BY A PE IT APPLICATION-FORM A,UNLESS A CURRENT FORFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TAN FORM B (12-91) FGRKWIM `/