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~ STATE OF CALIFORNIA *Maw .";.,;; o • STATE WATER RESOURCES CONTROL BOARD , UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �o COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. `•��•o.�' MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 7 PER CLO ❑ ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a >D ck S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIEAR) D. TANK CAPACITY IN GALLONS: s O ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O 1a REGULAR o 3 DIESEL ❑ 2 PETROLEUM ❑ W EMPTY ❑ i PRODUCT UNLEADED ❑ 4 OASAHOL ❑ e AVIATION GAS O 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE O 1bUNLEAIDED O 5 JET FUEL ❑ 7 METHANOL 2 LEADED ❑ g9 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B,ANDC,ANDALLTHAT APPLIES INBOX GANG A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 95 UNKNOWN 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) O W OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 6 100% METHANOL COMPATIBLE W/FRP (PNmwyTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ ❑ 2 ALKYD LINING 3 EPDXY LINING 4 C.INTERIOR 1 RUBBER LINED ❑ ❑ PHENOLIC LINING LINING ❑ 5 GLASS LINING g UNLINED ED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YESA. NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �'yg UNKNOWN O gg OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) AIA ^^�� OVERFILL PREVENTION EQUIPMENT INSTALLED((YEAR) W.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 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 W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESSTESTING ❑ 3 MONRORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIR)g EP DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [—] NO O �V �} SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (VRINTEO 8 SIGNRNHE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY a JURISDICTION a FACILITY a TANK a STATE I.D.# PERMITNUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATIQN•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 1 FILE THIS FORM WrrH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS �L \ FORM B (1291) I 3 FOR000gF6 // �—I — H \�\1