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• STATE OF CALIFORNIA • •'^ewe„ a9 et STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FORE CH TANK SYSTEM d MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 7 PERMANENTLY ❑ 5 CHANGE OF INFORMATION (T- ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETEALLITEMS- SPECIFY IF UNKNOWN N7 A. OWNER'S TANK I.D.i / S. MANUFACTURED BY: /1 C. DATE INSTALLED(MOrDAYA'EAR) I D. TANK CAPACITY IN GALLONS:!/� �0O n1S S IFA-11S MARKED,COMPLETE ITEM C. A. VEHICLE FUEL ❑ 4 OIL 9, O to REGULAR 3 DIESEL EUM UNLEADED ❑ e AVIATION GAS F7 ❑ 90 EMPTY I PRODUCT ❑ 16 PREMIUM 4 GASAHOI ❑ y METHANOL L PRODUCT ❑ % UNKNOWN ❑ 2 WASTE UNLEADED 5 JET FUEL2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) KED, ENTER NAME OF SUBSTANCE STORED C.A.S.Jr: III. TANK CONSTRUCTION MARKONE ITEM ONLYINBOXESA.B,ANDC,ANOALLTHATAPPLIESINBOXD A. ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER :F05 :BRI E STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCc'DPLASTIC L CRETE ❑ e POLWINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FgP) ❑ 10 GALVANIZED STEEL ❑ % UNKNOWN ❑ g9 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LW WG ❑ 3 EPDXY LINING ❑ 4 PHENOLK: LINING C.INTERIOR ❑ s � LINING LINING ❑ 8 UNLINED ❑ % UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 71 % OTHER s CATHODIC PROTECTION ❑ gt NONE ❑ UNIPIOWN ❑ 9g IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN 4 U 99 OTHER C. MATERIAL AND A U I 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 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVAN17ED 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 TESTING31NT S I IAL ❑ MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED CUANTITY OF SUBSTANCE REMAININGGALLONS 3.WAS TANK FILLED WITH YES C] NO ❑ INERT MATERIAL T THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME 1PRINTED a 311 DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNT`/# JURISDICTION# FACILITY# TANK# PERMIT NUMBER PERMITAPPROVED SY/DATE L. PERMIT EXPIRATION DATE FORM B 19.90) THIS FORM MUST BE ACCOMPANIED BY A PERMR APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORNMIS--RVI /^/)