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STATE OF CALIFORNIA • �<+°�� ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH T K SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED ON SI ❑ d AMENDED PERMIT � 8 TEMPORARY TANK CLOSURE ❑ S TANK REMO D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 9 Y I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# f S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) �« ✓ C D. TANK CAPACITY IN GALLONS: II.TANKCO NTS IFA-11S MARKED,COMPLETE ITEM C. A. I MOTOR VEHICLE FUEL ❑ 4 OIL B. C /e REGULAq 3 DIESEL ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ ibUNLEADED EM UM 8 ❑ 7 METHANOL 6 AVIATION AS 4 GASAHOL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE _ NLEADED O 5 JET FUEL 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A,1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND LMATERIAL E OF ❑ 1DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINERSTEM ❑ ❑ es uNKNOWW2 SINGLE WALL 4 SECONDARY CONTAINMENTNAULTEDTANp ❑ 99 OTHERANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUMryTank) ❑ 9 BRONZE ❑ 9 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING C.INTERIOR ❑ ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 5-6-`UNLINED ❑ a5 UNKNOWN ❑ 99 OTHER IS UNING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ PROTECTION 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION NONE ❑ 95 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 -f SUCT A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U SING A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER LD. LEAK ERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE RROSION A U S ALUMINUM A U B CONCRETE TECTION q U g GgLVANIZED STEEL A U 7 STEEL W/COATING q U 8 100% METHANOL COMPATIBLE W/FgP A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 IN V.TANK LEAK DETECTION MONITORING ❑ 99 OTHER ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAOOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 7 WAS TANK FILLED WITH GALLONS INERTMATERIAL7 YES E] NO THIS FORM HAS BEEN COMPLETED ED 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.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# "—FACILITY# STATE I.D.# 3 / TA NK# �A4/ic 65 PERMIT NUMBER PERMIT APPROVED BY/DATE / PERMIT EXPIRATION DATE FORM 8 (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FIL413. Y