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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE RM FOR TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT CHANGE OF INFORMATION ❑ ERMA NTLY CLO ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TE a TANK MOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: If N cc) I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.x B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAVryEAq) D. TANK CAPACITY IN GALLONS: ILTAN CO NTS FA-11SMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL ❑ . ULAR 3 DIESEL 2 PETROLEUM 80 EMPTY B 1 PRODUCT D 1b PREMIUMUNLEADE ❑ q GASAHOL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF(A.7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 2 LEADED a ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.x: III. TANK CONSTRUCTION MARKONE ITEMONLVIN BOXES A,B,ANDC72ALKYL 4MDALL THATAPPLIESINBOXDANDE A. TYPE OF ❑ 1 DOUBLE WALL NGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 95 UNKNOWN ❑ 2 SINGLE WALL CONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ INLESS STEEL ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ LYVINYL CHLORIDE ❑ 7 ALUMINUM (Primary Tenk) ❑ g BRONZE ❑ e 100% METHANOL COMPATIBLE W/FRP ❑ LVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ YD LINING C.INTERIOR ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LININGLINING ❑ 5 GLASS LINING ❑ INED ❑ 95 UNKNOWN ❑ 99 OTHERIS LINING MATERIAL DOMPATIBLE WMETHANOL? VES_ NO_IDCORROSION ❑ 1 POLYETHYLENE WRAP ❑ TINGPROTECTION ❑ 3 VINYL Wqqp ❑ q FIBERGLASS REINFORCED PLASTIC❑ 5 CATHODIC PROTECTION ❑ NE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 B. CONSTRUCTION A U A u 3 GRAVITY A U 99 OTHER 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH C. MATERIAL AND A U 1 BARE STEEL E U 95 UNKNOWN p I 99 OTHER A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 8 CONCRETE PROTECTION A U 9 GALVANIZED STEEL A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 A V.TANK LEAK DETECTION MONITORING ❑99 OTHER ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH GALLONS INERTMATERIAL? ES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG , IS TRUE AND CORRECT APPLICANPS NAME (iRINTEUb SIGNATURE) TE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR N S BELO g2,COUNTY# JURISDICTION# FACILITY STATE 04I� � ANK# PERMITNUMBER PERMITAPPROVED BY/DATE PERMIT E RATIONDATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATIO •FORMA,UNLESS A ENT FORM A HAS BEEN FILED. FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTIN E UNDER D STORAGE TANK REGULATIONS 0 is 4-0- F00=8-146