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• • a ! ''� C 4 STATE OF CALIFORNIA 'o STATE WATER RESOURCES CONTROL BOARD w., � ,�o UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B `.o .,,,, 1 �> . n0 N.� 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 ITEM ❑ 2 INTERIM PERMIT [:] 4 AMENDED PERMIT F7 g TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z yoZ 4 C I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN B. MANUFACTURED BY: A. OWNER'S TANK LD.a C. DATEINSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: �(f' ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. eREGU LAR 3 DIESEL ❑ 6 AVIATION GAS LDIrF(A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. UNLEADED 4 GASAHOL 7 METHANOL PREMIUM 2 PETROLEUM ❑ 80 EMPTY RODUCT ❑ 1bUNLEAD D ❑ 5 JET FUEL3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.III: 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 rMATERIA=LD OF ❑ 99 OTHER EM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC K ❑ g pOLWINYI CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP CONCRETE TaBRONZE ❑ 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 5 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO_ O.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING AP 4 FIBERGLASS REINFORCED PLASTIC ❑ 3 VINYL WR ❑ PROTECTION � 5 CATHODIC PROTECTION 91 NONE UNKNOWN ❑ 99 OTHER El E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDORU IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(D2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 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 B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95)PNKNOWN A U 99 OTHER D. LEAK DETECTION �TOMATIC LINE LEAK DETECTOR E�j-,2-LIN€TIGHTNESS TESTING L---J MONITORING ❑ 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 3.WAS TANK FILLED WITH S I IMATED QUANTITY OF 1.ESTIMATED DATE LAST USED(MOD2. SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDUGEE IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 8 SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY 0 T,ANK# STATE I.D.# ® 2 Z L G PERMITNUMBER PERMIT APPROVED BV/DST O�.�jG PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•77F3UKM A.UNLESS A CURRENT FORM A HAS BEEN FILED. y� FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (1291) 0 0