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• � souPce !w pp4' P STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B p1l,eOPN,P COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ❑ 3 ;RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY 1 NEW PERMIT ❑ g TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEDONE ITEM 2 INTERIM PERMIT ❑ 4 DED PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4, /oliek I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: A, OWNER'S TANK I.D.# D.TANK CAPACITY IN GALLONS: �/o C. DATE INSTALLED(MOIOAY/YEAR) %, II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS 0-1 MOTOR VEHICLE FUEL ED OIL B. C. ❑ UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL A PRE I ❑ 2 PETROLEUM El so EMPTY ® 1 PRODUCT ❑ 1bUNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S. D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARKONEITEMONLYINSOXESA,B,ANDC,ANDALLTHATAPPLIES INBOX O AND ❑ 3 SINGLE WALL WITH EXTERIOR LINERANIq ❑ 95 UNKNOWN A. TYPE OF F-] 1 DOUBLE WALL 99 OTHER J SYSTEM ❑ 2 SINGLE WALL [:] 4 SECONDARY CONTAINMENT (VAULTED T ❑ ❑ L BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100'% METHANOL COMPATIBLE WIFRP MATERIAL ❑ 6 CONCRETE E] 99 OTHER (PrimaryTenk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 6 GLASS LINING LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— — ❑ 2 COATING n 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ 1 POLYETHYLENE WRAP '–C PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICA13LE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A..U -95 UNKNOWN A U BB 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 WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A_U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 99 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING E-191 NONE El 95 UNKNOWN ❑ OTHER VI.TANK CLOSURE INFORMATION �,, y ANK FILLED WITH YES ❑ NO ❑ 2.ESTIMATED QUANTITY OF �- - ERT MATERIAL? 1.ESTIMATED DATE LAST USED(MO/DAV/VR) SUBSTANCE REMAINING THIS FORM H S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO HBEST NOWLEDOGEE IS TRUE AND CORRECT APPLICANTS NAME (PRINTED AS NATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION# FACILITY# _ STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORMWITHTCAL AGENCY IMPLEMENTINGTHE UNDERGROUND ST02AGETANK REGULATIONS POROUS- FORMS (1291)