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STATE QFCAUFORNIA 0- � STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. i MARK ONLY ❑ 1 NEW PERMIT ❑ ] RENEWAL PERMIT �. 5 CHANGE OF INFORMATION f P M/ANENTI;Y CLOSED ON ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK R6MOyED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• I 3. MANUFACTURED 8Y: C. GATE ,NSTALLED(MO/DAYNEAR) 0. TANK CAPACITY IN GALLONS: =NTENTSS FA-I ISMARKED.COMPLETE ITEM C.VEHICLE FUEL ;❑ A OIL g C. to REGULAR 3 DIESEL ❑ 6 AVIATION GAS UNLEADED LY J'1 a GASAHOLEUM ❑ W EMPTY 1 PROOucT IO PREMIUM 7 METHANOL UNLEADED 5 JET FUEL AL PRODUCT j 95 UNKNOWN ❑ 2 WASTE I❑ 2I'_AOED 99 OTHER (DESCRIBE IN ITEM D. BELOWIRKED. ENTEfl NAME OF SUBSTANCE STORED C.A.S.A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN ROX D AND A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LWER IJ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER I❑ I BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS I❑ a STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC S TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM I❑ 6 100% METHANOL COMPATIBLE WIFRP (Pnmary Tank) ❑ 9 BRONZE ❑ TO GALVANIZED STEEL 95 UNKNOWN ;❑ 99 OTHER '❑ I RUBBER UNED ❑ 2 ALKYD LNNG f— 3 EPDXY LINING i❑ A PHENOLIC LINING C.INTERIOR i-T 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN j❑ 99 OTHER UNING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL' YES_ NO_ D.CORROSION ❑ I POLYETHYLENE 'WRAP ❑I 2 COATING 1 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION J 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN I❑ 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 U I 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 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC1A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U 3 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U N OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TES TING `'; MONROPING a 99 OTHER V.TANK LEAK DETECTION I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITORING ❑ A AUTOMATIC TANK GAUGING U 5 GROUND WA TER MONITORING 6 TANK TESTING `i 7 INTERSTITIAL MONITORING ❑ 91 .NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED GATE LAST USED(MOIDAYNR) Z.ESTIMATED QUANTITY OF 3-WAS TANK SH I ED WITH YES IL^� NO i _ SUBSTANCE REMAINING GALLONS INERT MATERIAL' THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME GATE PRINTED.SIGNATUREII LOCAL AGENCY USE ONLY THE STATE I.O.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW CVS COUNTY, JURISDICTION 9 FACILITY; TANE#9 STATE I.D. °ERMIT NUMBER PERMIT APPROVED SYIOATE 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 =ORM3 (12-91) • . FOR9¢3f Bp6 /r I