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tb Vn f ' STATE OF CALIFORMA " s STATE WATER RESOURCES CONTROL BOARD 3 a� o ii UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �,. o C4 oon Mr COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE '><8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1S-- I f-k sr rl J-3 I. TANK DESCRIPTION COMPLETE ALL ITEMS–SPECIFY IF UNKNOWN LC.A. OWNERS TANK I.D.a B. MANUFACTURED BY: DATE INSTALLE O/DAY/YEAR) V D. TANK CAPACITY IN GALLONS: L ILTANKC ENTS IFA-11S MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ 18UNLEADED REGULAR3 DIESEL ❑ g AVIATIONGAS 2 PETROLEUM ❑ 4 GASAHOL ❑ 80 EMPTY 1 PRODUCT 1bUNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT O 95 UNKNOWN '❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALLTHAT APPLIES IN BOX A. TYPE OF ❑ 1 BILE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 81 GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL F–] 2 STAINLESS STEEL E] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP ❑ (DrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EP LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 GLASS LINING ❑ 6 UNLINED ElrQ6 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION F-191 NONE 5 UNKNOWN E–] 99 OTHER 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 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 5 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 U 4 FIBERGLASS PIPE y' CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP 11V PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL ❑99 OTHER V. ANK LEAK DETECTION ` ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING N ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE E:] 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTI ATfcD DATE LAST USED( /DAYIVR) 2.ESTIMATED QUANTITY OF a sa INERTMATERIAL7 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE IPRINTEG b SiGNeTIIRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW n COUNTY# JURISDICTION# FACILITY# TANK# TATE I.D. �] b 0 I UMBER PERMIT APPROVED BY/DATE PE MIT EXPIRATION DATE 101 614z� FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.