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SUY"-p STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s ' UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B J- COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLO ONE ITEM r72 INTERIM PERMIT F74 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7 H IMi I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# ✓ B. MANUFACTURED BY: �� C. DATE INSTALLED(MO/DAY/YEAR) � D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETEITEM C. IaREGULAR 3 DIESEL A 'X I MOTOR 2 PETROLEUM FUEL ❑ OIPry B' PRODUCT O ❑ lbPREMIUM UNLEADED ❑ 4 GASAHOL ❑ 8 AVIATION GAS ❑ O ❑ ❑ ❑ 7 METHANOL lll"�—�"��- UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 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.S: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.ANDC,ANDALLTHAT APPLIES INBOX D AND A. TYPE OF ❑{ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 1��y 2 SINGLE WALL ❑ 4 .SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK i RARE STEEL ❑ 2 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 (PlimaryTNk) ❑ 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 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES , NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)ALaz OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 IV B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN11 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 CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOfl ❑ 2 LINE TGHTNESS TESTING ❑ O MONITORING OTHER INTERSTrTIAL V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMADATE r&SIED(M Y.CTR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AfJD TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRIMEDb SKMAWRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUM W COUNITY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMITNUMBER PERMIT APPROVED BY/DATE RMIT R THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM (12-91) .C7B FORO6A9-R6