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• STATEOFCAUFORNA % ��; STATE WATER RESOURCES CONTROL BOARD + AMARKUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B 3.,,, o°COMPLETE A SEPARATE FORM FOR TANK SYSTEM.ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK R ED v CBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 0. TANK CAPACITY IN GALLONS: ILTANK NTENTS IFA-1 ISMARKED.COMPLE I E ITEM C. � to REGULAR 3 DIESEL 6AVIATION GAS A 1 MOTOR VE4ICLE FUEL 'J A OIL 8. C. ❑ UNLEADED s GASAHOL ❑ 2 PETROLEUM ❑ W EMPTY I I PRODUCT ❑ lb PREMIUM T METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN I ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. SELCWI 0. :F(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED / ——q C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,a.AND C.AND ALL T4AT APPLIES IN BOX C AND — 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 11 1 BARE STEEL j❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK j g pOLWINYI CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP MATERIAL !_ 5 CONCRETE (PrimaryTank) Ji 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN IJ 99 OTHER 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ A PHENOLIC LINING C.INTERIOR �❑ 5 GLASS LINING I a UNLINED ❑ % UNKNOWN U 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100Y. METHANOL? YES_ NO_ O.CORROSION 1 POLYETHYLENE WRAP I—I 2 COATING ❑ 3 VINYL WRAP ❑ t FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION �❑ 9T NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAWMENT INSTALLED(YEAR) OVERFILL PREVENTION ECUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPUCASLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 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 A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELWI COATING A U 8 100% METHANOL CCMPATIBLE WIFRP PROTECTION A U 9 GALVANQEO STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ I AUTOMATIC UNE LEAK DETECTOR ❑ 2 UNE TIGHTNESS TESTING ❑ )'MONRORING ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ a TANK TESTING I❑ 7 INTERSTITIAL MONITORING a 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIOAYNR) I 2.ESTIMATED OUANTRYOF 3.WAS TANK FILLED WITH YES ^-I NO I` SUBSTANCE REMAINING GALLONS IN MATERIAL? L� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE ��/ IPPINTE9 A SIGNATURE( ✓Y7 LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY x TANK x STATE I.D.;# 1--i"T = ! PERMIT NUMBER PERMIT APPROVED BY10ATE PERMIT EXPIRATION OATS THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETANK REGULATK)N8 FORM B (1291) WP06it8.T6 /�