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STATE OF CALIFORNIA , o STATE WATER RESOURCES CONTROL BOARD y a ANK PERMIT APPLICATION - FORM B UNpERGROl1ND ;TORAGE T COMPLETE ASEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY LOSED ON S1 ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 8 TANK REMOV D MARK ONLY ❑❑ 1 NEW PERMIT b AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ONE ITEM 2 INTERIM PERMIT El DSA OR FACILITY NAME WHERE TANK IS INSTALLED: :! I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B MANUFACTURED BY: < A OWNER'S TANK 1.D.M f D. TANK CAPAC%TY IN GALLONS: C. DATE INSTALLED(MUDAYIYEAR) / II.TANKC EMS IFA-11SMARKED,COMPLETE ITEM C. aREGULAR � 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 OIL B. C. UNLEADED 4 GASAHOL ❑ 7 METHANOL 1 MOTOR VEHICLE FUEL 1 PRODUCT ❑ 1C PREMIUM 5 JET FUEL A ❑ 2 PETROLEUM ❑ 60 EMPTY UNLEADED ❑ 95 UNKNOWN ❑ 2 WASTE El LEADED ❑ 99 OTHER {DESCRIBE IN ITEM D. BELOW} 3 CHEMICAL PRODUCT C.A.S.9: D. IF(A.11 IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED III TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES 1N BOX D❑85 UNKNOWN 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINEA A. TYPE OF ❑ 99 OTHER ❑ SYSTEM GLE WALL 4 SECONDARY CONTAINMENT {VAULTED TANK) 2 SSN ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ b STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 1 BARE STEEL 9. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ s 100% METHANOL COMPATIBLE WdFRP MATERIAL 71 5 CONCRETE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER (Primary Tank) [:3 9 BRONZE [:11 RUBBER LINED a 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ b PHENOLIC LINING C.INTERIOR r 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER 5 GLASS LINING LINING 15 LINING MATERIAL COMPATIBLE WITH 1009'- METHANOL? YES_ NO 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 91 NONE KNOWN ❑I 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 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 Ao 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 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 1001!. METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A095 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTE9S IT ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECKINVENTORY RECONCILIATION ❑ 3 VADOZE MCNITCRING 4 AUTOMATIC TAMC GAUGING 5 GROUND WATER MONITORING fANK TESTING 0 7 INTERSTITIAL MONITORING CI 91 NONE ❑ 95 UNKNOWN ❑ 99 OTWA VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED{MOrDAY/YR) 2.ESTIMATED OUANTr Y OF 3.WAS'ANK FILLED WITH SUBSTANCE REMAINING GALLONS NEPT(AAT cfYIFt? YES '. mo Q THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW CCUN # JURISDICTION# FACILITY# TANK# r-\J STATE 1.D.# 1LLJI I ec' PERM[TNUMBER PERMIT APPROVEDBYIOATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. �OR9�3d8-�75�