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STATE OFCALIFORNIA *Aw/ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B oy' of COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM °•,,,o„�r;• 'o MARK ONLY ❑ 1 NEW PERMIT ONE REM ❑ 3 RENEWAL PERMIT O ❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ITE ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O B TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' T-Z_ GSL I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# v. S. MANUFACTURED BY: C DATE INSTALLED(MO/DAY/YEAR) EK' ' O. TANK CAPACITY IN GALLONS: `' II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. v A. ❑ 1 MOTOR VEHICLE FUEL ❑ q OIL B. 1AREGULAR o ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT C ❑ UNLEADED O 4 DIESEL ❑ 6 AVIATION GAS ❑ ib PREMIUM ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT [ 9 KNOWN ❑ 2 WASTE ❑ 2 UNLEADED LEADELEADED ❑ 5 JET FUEL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.ANDALLTHATAPPLIES IN BOXD AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ ! STEEL CLAD WI FIBERGLASS REINFOFK:ED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrlmtryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3XY LINING ❑ 4 PHENOLIC LINING O INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED LINING95 UNKNOWN ❑ 90 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING �VL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC F-1PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND ORUIFUNDERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 RARE 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 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A&;6 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ N OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ ! 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/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO [7]SUBSTANCE 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 b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# p PERMITNUMBEq PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE—D. ,� FORMIW%