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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 ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED tS 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALLITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.* 8. MANUFACTURED BY: C. DATE INSTALLED(MO/DAVA'EAR) D. TANK CAPACITY IN GALLONS: flLA II.TAN K CONTENTS IFA.7ISMARKED,COMPLETE ITEM C. (l A. OTOR VEHICLE FUEL ❑ 4 OIL B. 1.REGULAR TROLEUM ❑ W EMPTY 0. ❑ UNLEADED 3DIESEL 6 AVIATIONGAS ir 1 PRODUCT 1bPREMIUM ❑ 4 GASAHOL EMICAL PRODUCT ❑ 95 UNKNOWN r ❑— 2 WASTE UNLEADED ❑ 5 JET FUEL 7 METHANOL 2 D ❑ gg OTHER (DESCRIBE IN ITEM D. eELOWI T MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8 AND C.AND ALL THAT APPLIES IN BOX DANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2 SINGLE WALL ❑ ❑ 95 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS MATERIAL /''❑ ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ C.INTERIOR yam,` ❑ 4 PHENOLC LINING LINING ❑ 5 GLASS LINING 1y�6 UNLINED ❑ �/"� 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 _ YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 3 VINYL WRAP ❑ q FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ gg OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY p U 99 OTHER B. CONSTRUCTION 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 5 ALUMINUM A U 6 CONCRETE U 7 STEEL COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 955 UNKNOWN p U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING3 ❑ MONRORING 99 OTHER 5/ '� V.TANK LEAK DETECTION ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ES AT DATE LAT ED(MD/DAV/YR) 2.ESTIMATED QUANTITY OF 19. SUBSTANCE REMAINING ''r-T- 3.WAS TANK FILLED WITH GALLONS INERTMA7ERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ACILITY COUNTY# JURISDICTION# //7/ STATE I.D.# mFFA # TANK# PERMITNUMSER E ERMIT APPROVED BV/DATE PERMIT E%PIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS fOR09I98-136