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i •STATE Of CALIFORNIA STATE WATER RESOURCES CONTROL BOARD iy UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ < AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z �� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.8 � 01� B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. C. 1AUNLEADED3 DIESEL g AVIATIONGAS At MOTOR VEHICLE FUEL d OIL 4 GASAHOL ❑ 2 PETROLEUM y 80 EMPTY ❑ I PRODUCT ❑ 11:)UNLEADED5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPROOUCT /—❑ 95 UNKNOWN C:] 2 WASTE El2 LEADED 9g 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.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ff 2 SINGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK ❑ g POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL MPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE ,, i,,,� (PdmuyTA0k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL zffil'95 UNKNOWN ❑ 99 OTHER l/y); !ry � ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING EPDXY LINING ❑ d PHENOLIC LINING '^ _ C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 96 UNKNOWN ❑ 99 OTHER y `� — LINING LS LINING MATERIAL COMPATIBLE WITH 1DD% METHANOL? YES— NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 96 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR 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 S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A Il 95 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 d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI COATING A U B 100% METH CNOL MPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOICPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORING ❑ 90 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE 7 SED(MOIDAYA'R) I 2 ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE IPAINNX A$KWAMM LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW kt, COUNTY x JURISDICTION x FACILITY x TANK x STATE I.D.# m FTT1 / 0 -7 r) PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ' FOROQt4g R, i �