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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD nF e e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B e MARK ONLY 1 NEW PERMIT COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ` D- ❑ ONE ITEM 2 INTERIM PE❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION RMIT ❑❑ 4 AMENDED PERMIT 7 PERMANENTLY CLOSED ON SITE 6 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �'O /❑ B TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. a C. DATE INSTALLED(MO/DAYIYEAR) B. MANUFACTURED BY: IIJANKCONTENTSFA-1 IS MARKED,COMPLETE ITEMC. O• TANK CAPACITY IN GALLONS: 5 QOO A. ❑ 1 MOTOR VEHICLE FUEL 04c B. RC1 2 PETROLEUM C. ❑ 1a REGULAR 3 DIESEL 6 AVIATION GAS ❑ 1 PRODD eD EMPTY UCT UNLEADE ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ lb PREMI D 5 ETFUELL ❑ ❑ 2 WASTE ❑ 7 METHANOL D. IF(p.7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E C A'S. A. TYPE OF ❑ 7 DOUBLE WALL SYSTEM �7�r�" ❑ 3 SINGLE WITH EXTERIOR LINER �^ 2 SINGLE WALL ❑ q SECONDARYARY CONTAINMENT (VAULTEOTAN ❑ 95 UNKNOWN 1 BARE ❑ OTHER STEEL B. TANK ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC (PrimaryTank) ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 BRONZE El 100% METHANOL COMPATIBLE W/FRP El 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 1 RUBBER LINED ❑ OTHER C.INTERIOR ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING LINING ❑ 5 GLASS LINING ❑ 4 PHENOLIC LINING 6 UNLINED ❑ 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ❑ OTHER YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 5 CATHODIC PgOTECTION_�<91 NONE ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 85 UNKNOWN E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND,BOTH OVERFILL TK)N EQUIPMENT INSTALLED F APPLICAB EYEAR) A. SYSTEM TYPE 7 SUCTION A U 2PRESSURE 09 A U 3 GRAVITY B. CONSTRUCTION A U 99 OTHER A 1 SINGLE WALL A U 2 DOUBLE WALL {° U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U CORROSION A U 5 ALUMINUM A U 6 CONCRETE 4 FIBERGLASS PIPE PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODCPROTECT ON 7 STEEL W/COATING A U 8 100% METHANOL COMPATISLEW/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ J V.TANK LEAK DETECTION MONRORING 9B OTHER Q - ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING ❑ 6 TAN(TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN El 99 OTHER VL TANK CLOSURE INFORMATION Lf ESTIMATE D E LAST.USED(MO/DAY/YR) 2.ESTIMATED QUANT_ YfY OF SUBSTANCE REMAINING 3.WAS TANK FILLEDWITH GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMCOMPOSED OFTHE FOUR NUMBERS BELOW D Try COUNTY N JURISDICTION aY V O 5" STATE I.D.# FACILITY TANK# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (12-91) FILE THIS FORM WITH AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS +� as� 9s FORD( WBAS