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UR,e 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 CLOSED ON SITE ONElTEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: � � (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN r' A. OWNER'S TANK I.D.# B. MANUFACTURED BY: y�, C. DATE INSTALLED(MO DAYMI AR) �� -47�3 D. SANK CAPACITY IN GALLONS; ILTANKCONTENTS )FA-1 IS MARKED.COMPLETE ITEM C. ❑ 4 OIL B. C. 1aREGULARUN UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A �i MOTOR VEHICLE FUEL ,�,/ ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY X 1 PRODUCT ❑ 1bPREMUNL I UM ADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN J❑�`2 WASTE ❑ 2 LEADED ❑ gg 0-HER (DESCRIBE IN ITEM D. BELOW} D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A,S.# III. TANK CONSTRUCTION MARKONEITEM ONLY INBOXES A,B,ANDC,ANDALLTHATAPPLIES INBOXDANDE 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF99 OTHER ❑ SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS X4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC 5 CONCRETE B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W1FRP MATERIAL ❑ (PrimaryTank} ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F7 2 ALKY'O LINING F] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES X NO— [-:] O_❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 95 UNKNOWN 99 OTHER 91 NONE ❑ ❑ 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 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 CTHER 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) U FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W!COATING A 6 100% METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED 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 TESTING ❑ 31 STI AMONITORING ❑ OTHER V.TANK LEAK DETECTION 7] 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING E] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING IV7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ 1.ESTIMATED dAT A T (MOIDAYN I SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY JCNOWLEDOG IS TRUE AND CORRECT ATE EAPPLICANTS NAME RINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D,NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW fj COUNTY# JURISDICTION# FACILITY# TANK# L/ ct STATE I.D.# �❑ Flaw[u Qal]L]* PERMIT NUMOER PERMIT APPROVED BYIDATE PERMIT EXPIRATION BATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. y FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS R / �fl49-R8 FOAM 8 (12-91) y- � f i`�'U�J "'- ,� 1 �-7 I