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o • f STATE OF CAUPoiPiA fo STATE WATER RESOURCES CONTROL BOARD N'• +� �� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SfiE ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE 5 DSA OR FACILITY NAME WHERE TANK IS INSTALLED: ' o a 5 A-R, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A.OWNEWS TANK L D.a B. MANUFACTURED BY: C. DATE INST EO(MGIOAYIYEAR) 1 D. TANK CAPACITY IN GALLONS: ILTANK NTENTS FA-1 IS MARKED/.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ a OIL 8. C. 1aU ENLEAD R 0 DIESEL ❑ 8 AVIATION OAS ❑ 2 PETROLEUM ❑ 00 EMPTY 1 PRODUCT ❑ tb PREMIUM 8 a GASAFIOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 0 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.BAND C,ANDALLTHAT APPLIES IN 80X0 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 0 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANTO ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ S FIBERGLASS ❑ a STEEL CLAD WN FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WFRP (Pnmuy Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNW40WN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 0 EPDXY LINING a PHENOLIC LINING C.INTERIOR r7 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 90 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ i ,P:OLYETIMENE WRAP ❑ 2 COATING ❑ S VINYL WRAP O a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑96 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U S GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UNKNOWN A U 90 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL YGCOATING A U 8 100% METHANOL COMPATIBLE WFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC:LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ O NonRORwo ❑ 99 OTHER .TANK LEAK DETECTION V ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ S VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING V ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONITORNG ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2 ESTIMATED OUANT TY OF 0.WAS TANK FILLED WITH YES C:] ❑ SUBSTANCE REMAINING GALLONS INERTMATERWL? NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME PATE (PRx D s SIONAMM I LOCAL AGENCY USE ONLY THE STATE I.O.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY I JURISDICTION I FACILITY I TANK* STATE I.D.# m1 11 lz PERMIT NUMBER /LPERMIT APPROVED BY/GATE 'J . ERMIT EXPIRATK)N DATE FORM B (9.9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. PoROOINBM