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STATE OF CALIFORNIA 10 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B • Cltln O,l YY COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED:2'5%7 0 1 TANV hCQy`DIDTIflN o, CTC Al I ITFUR.. 9PPMPY IF I INKNOWN A. OWNER'S TANK I. D. N Z B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: MOTOR VEHICLE FUEL ❑ 4 OIL B. O. ❑ la aUN REGULAREA ED ❑ 3 DIESEL ❑ 6 AVIATIONGAS A ❑ 2 PETROLEUM ❑ B6 EMPTY —E7-1 P T PREMIUM ❑ ❑ 4 GASAHOL ❑ 7 METHANOL 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE UNLEADED ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: UI TMIV / MKICTDIIPTVV,i e P ANno ANTIAII TUATAPPI IFSINROXn ANDS III nTl\IC IKIEMORRATV1M nnni ninno II ¢ cPr Dnl Mn Di -ITU IF APPI V`dRI F A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U ❑ 1 L ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER 2 DOUBLE WALL A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC S. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E�IWN ❑ 99 OTHER MONITORING ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINEDUNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL Pte❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) III nTl\IC IKIEMORRATV1M nnni ninno II ¢ cPr Dnl Mn Di -ITU IF APPI V`dRI F A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U i BARE STEEL 5 ALUMINUM 9 D STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 7 STEEL W/COATING A U UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR �4 E TIGHTNESS TESTING ❑ MONITORING L] 99 OTHER V TANV I Fel[ nFTFr..TInN ❑ 1 VISUAL CHECKVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES E] NO ❑ SUB STAN CE 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 DATE (PRINTED A SIGNATURE) I Or AI A( PKI(W I ISF OM V THF STATF in NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY A JURISDICTION # FACILITY # TANK # STATE I.D.# PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DAT THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORMA NAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND �STOR—AGE TANK REGULATIONS FORM B (12-91) • R q 4 J� 1