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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑, 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDDf�jz:E ONE ITEM �❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLCSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 9 �jr I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.x /'1-7_ B. MANUFACTURED BY: C. DATE INSTALLED(MQiDAY YEAR) Q. TANK CAPACBTY IN GALLONS: !_ ii II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. MOTOR VEHICLE FUEL n 4 OIL g, C ❑ to REGULAR 3 DIESEL UNLEADED ❑ ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 90 EMPTY1 PROpUCT PREMIUM 4 GASAHOL 7 METHANOL u `UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT F7 ❑95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOW) D. IF{A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED G.A.S.x IIP. 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 WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER gOV N SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Q 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100.1 METHANOL COMPATIBLE W1FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEELNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING r73 EPDXY LINING ❑ 4 PHENOLIC LINING C INTERIOR 5 GLASS LINING ❑ 6 UNLINED �S�ifCKNOWN ❑� 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1009; METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP �❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE F9%L - ❑ 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 1)SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 49 OTHER B, CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A . 5 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 B CONCRETE A U 7 STEEL ,W/ A U 6 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 9A UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONITORING L,! 99 OTHER V.TANK LEAK DETECTION l_ 1 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING E 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MCWTORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONEUNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1,ESTIMATED DATE LAST USED(MCIDAYIYR) I 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH F SUBSTANCE REMAfNING 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 (PRINTED 6 SIGNATURE) DATE � LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BER ---�ELOW ❑� COUNTY# JURISDICTION# FACILITY# TANK# STATE f.D.# � III----SIL--SIL-J-II ❑ r PERMfTNUMBER PERMIT APPROVEDBYIDATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROW48-R5