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• • ! , STATE OF CALIFORNIA W �' STATE WATER RESOURCES CONTROL BOARD + o 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 D 7 PERMANENTLY CLOSED ON SIT \A ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.# 3 E B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) V w/k../JOW M D. TANK CAPACITY IN GALLONS: II•TANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. REG ULARo LIF ❑ 1aUNLEADED ❑ 4 GASAHOL 3 DIESEL ❑ 6 AVIATION GAS MOTOR VEHICLE FUEL ❑ 4 OIL B. G PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1bPRE UNLEAIUM DED ❑ 5 JETFUEL ❑ 7 METHANOL CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) NOT MARKED, ENTER NAME OF SUBSTANCE STORED F/�'�P C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 1 BARE STEEL F-] 2 STAINLESS STEEL E] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP ❑ (PrimaryTank) ❑ 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 WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UeS5 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 A U 3 GRAVITY A®99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A®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 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 p 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TES TING ❑ 3 MONBORING ❑99 OTHER 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 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDSUBSTANCE REMAIN(OF 3.WAS TANK FILLED WITH VES ❑ NO❑ 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 DATE APPLICANTS NAME (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY K JURISDICTION A FACILITY N TANK 71 STATE I.D.# m = KulkgV 1,911917J PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE / '? Ir . THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED7� FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS f-0ROOM&A6 FORM (1291) • •