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• STATE OF CALIFORNIA t5Oop`B STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a "` ao COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. -Id MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 5 CHANGE OF INFORMATION 7 ANENTVE CLOSED ON 51T ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# Q B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYlYEAR) i/ // _ D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS FA-I IS MARKED,COMPLETE ITEM C. A. ❑ 1 M OR VEHICLE FUEL ❑ q OIL B. / 1a REGULAR ❑ PETROLEUM I--�( C ❑ UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ BO EMPTY IIJJ 1 PRODUCT ❑ in PREMIUM q GASAHOL ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 dETFUEL ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(q,1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCT) N MARKONE ITEM ONLY IN BOXESA,B,ANOC,AND ALL THAT APPLIES IN BOXDANDE A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ ❑ 95 UNKNOWN 4 2 SINGLE WALL SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ ARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM [1](Primary Tank) ❑ 9 BRONZE B 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 KYO LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ OATING ❑ 3 VINYL WRAP PROTECTION ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 96 UNKNOWN ❑ 99 OTHER E.SPILLANDOVERFILL SPILL CONTAINMENT INSTALLED(NEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY U ER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL q U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE PROTECTION U 7 STEEL COATING A U B 1METHANOL COMPATIBLE W/FRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION q U g55 OTHER UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 7 IN I MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 DOZE MONITORING ❑ q gUTOMATIC TANKGAUGING ❑ 5 GROUNDWATER MONITOR ING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(M /DAY/Y ) 2.ESTIMATED QUANTITY OF 7.� y SUBSTANCE REMAINING (/ GALLONS 3 WA INERT MATERIAL?S TANK FILLED H YES NO TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY APPLICANTS NAME KNOWLEDGE, IS TRUE AND CORRECT (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK XRY � LPERMITNUMEIER h�PE IRMIT APP—R—GIVE—D BLV/DJATE PERMIT)) IyATIONDATE /y/y FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENTT FORMA HHAASOBEEN FILED. / 0 • FOR00I4BR5