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• • !!•,ru.. !t, STATE OF CALIFORNIA ^! STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. b MARK ONLY ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ITE 1 NEW PERMIT ❑ ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ ❑ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN W 11- ' B. MANUFACTURED BY: Ow pI A. OWNER'S TANK I.D.x 1 C. DATE INSTALLED(MO/DAYNEAR) UL N KN 0�AI D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1a REGULAR O 3 DIESEL ❑ 6 AVIATIONGAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 1 PRODUCT C 10 PREMIUM o 4 GASAHOL ❑ 7 METHANOL A ❑ 2 PETROLEUM ❑ BO EMPTY ❑ ❑ UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELO" D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER SYSTEM 2 SINGLE WALL LK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLEWIFRP MATERIAL ❑ 5 CONCRETE )PdmsryTBnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 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 13 LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E] 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE X96 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVEGROUND OR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A1095 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL S/UNKNOWN A U 81000%% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING 70ZIKI OTHER tIA+KJVOWN V.TANK LEAK DETECTION ❑ 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 EX95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF VES E] NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION If FACILITY# STATE I.D.# PERMITNUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE /D ` / THIS FORM MUST BE. -- iz.;:NIED 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 FOR0934BR6 FORM 3 (1291) 0 0