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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BIj ly, , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. E ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS N SITE TEM ❑ 2 INTERIM PERMIT4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED / R FACIUTY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. B. MANUFACTURED BY: ^�T C. DATE INSTALLED(MOIDAY/YEAR) /V7 5-7 0, TANK CAPACITY IN GALLONS: !c;;>/ 00 0 IL TAN K C LATENTS IFA-1 1S MARKED,COMPLETE ITEM C. ❑ 1a3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL E-] 4 OIL B. C UNLEADED 94 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ tbPREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0, 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 14Ar] �OAi' r � �y 3` U"k r ? L 1�1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑� 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑] 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING D,INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED d95 UNKNOWN, ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION L-?'5 CATHODIC PROTECTION ❑ 91 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 o 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 B 1009/ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AUNKNOWN A U 99 OTHER ❑ MO7FSTlTIAL G ❑ D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VL TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO �I SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TROT AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# a �TFI� EEL= PERMIT NUMBER PERMIT APPROVED BYIDATE- PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) FOR0034B-R6