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N � STATE OF CAUPOR IA '�E STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� u° m �r . j. o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �""°""��. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E:] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM F—] 2 INTERIM PERMIT F--] 4 AMENDED PERMIT E] 8 TEMPORARY TANK CLOSURE Q S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 156 -v lo n I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTE IFA-1 IS MARKED,COMPLETE ITEM C. A. MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ IaUNLEA REGULAR ED DIESEL ❑ g AVIATION GAS ❑ 2 PETROLEUM E::] 80 EMPTY 1 PRODUCT El ib PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED E:]UNLEADED ❑ 5 JOTHERL(DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA.B,ANDC,AND ALLTHAT APPLIES INBOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 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 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICA13LE A. SYSTEM TYPE A(!! SUCTION A U 2 PRESSURE A U 3 GRAVITY A U N OTHER B. CONSTRUCTK7N A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A® BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP 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 DETECTORMONITORING ❑TECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITO G ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATELASTUSED IMO/DAY/YR) 2.ESTIMAQUANTITY OF 3.WAS TANK FILLED WITH YES NO L SUBSTANCTEDE REMAINING GALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# (t I C IS STATE 104 � PERMIT NUMBER '3PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE �L FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED C//ZInD/ ro