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STATE OF CALIFORNIA a ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FORE CN TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ ] PERMANENTLY CLOSED ONSITE ❑ 4 AMENDED PERMIT ❑ e TANK REMOVED TANK CLOSURE ❑ / f DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6 TE ! � �� I .i c- 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: rp ILTANKCO S IFA-11S MARKED,COMPLETE ITEM C. A. Laol MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ 1aREGULAR UN FADED I❑ 33 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT O ib PREMIUM ��GASAHOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN,`- WASTE UNLEADED - JET FUEL ❑ ] METHANOL 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED I C.A.S.#: O III. TANK CONSTRUCTION MARKONEIT ONLY IN BOXES A,8,AND C.AND ALLTHATAPPLIES INBOX DANDE A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARESTEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 1W, METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 0 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ e NLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 10 a METHANOL? YES_ NO— D.CORROSION O_D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 C TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NO E ❑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 IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRES RE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBL WALL A U 4.Y LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLE S STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRE A U 7 STEELW/COATING PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC ROTECTION A U 9 1METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 0OTHTHER D. LEAK DETECTION 0 1 AUTOMATIC UNY LEAK DETECTOR D 2 L E TIGHTNESS TESTING INTRMnl V.TANK LEAK DETECTION MONITORING ❑ 99 OTHER ❑ 1 VIS ]]CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING TANK 'PRSTING . ED NE 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER V1.TANK CLOSURE INFORMATION 1.ES TE TE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3 WAS MATERIAL L? YES ❑ ❑ GALLONS INERT MATERIAL. NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TD THE�BESTIMY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW , COUNTY# JURISDICTION# FACILITY# TANK# --Tl PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. • ] i u�, n FOR003/B-R5