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STATE OF CALIFORNIA _� 9 STATE WATER RESOURCES CONTROL BOARD 3 r r UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B leiI , . ,y COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE n�NK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: i� (/ I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK L D.11 4 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK C TS IFA-119 MARKED,COMPLETEITEM C. 1 MOTOR VEHICLE FUEL 4 OIL B. C ❑ 1a REGULAR 3 DIESEL ❑ 6 AVIATION GAS A. ❑ / UNLEADED E 2 PETROLEUM ❑ 80 EMPTY LL�''� PRODUCT ❑ ih PREMIUM 4 GASAHOL ❑ 7 METHANOL LEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE J�r2 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 E A. TYPE OF ❑ 1 DOUBLE LL F73 SINGLE WALL WITH EXTERIOR LINER 7] 96 UNKNOWN SYSTEM 712 SINGLE WAL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 1001 METHANOL COMPATIBLE WiFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR f-1 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING �J IS LINING MATERIAL COMPATIBLE TH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLF NE WRAP ❑ COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED( EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUN OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 P ESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DO�BLE 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 STA4-IESS 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 WICOATING A U 8 100% METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MTERSTI IA ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYlYR 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING 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 DATE (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW U�4dL IL� COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED_. 76 FO)03MB-95