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1p STATE OFCALIFORNIA �¢• °` i 6o.- STATE WATER RESOURCES CONTROL BOARD ;. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, �•`.°""1� MARK ONLY ❑ 1 NEW PERMIT D 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SEO ON SP ONE ITEM ❑ 2 INTERIM PERMIT a 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ol DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L 110 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D,* 1 H. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) C3 L D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETEITEM C. A, _1 MOTOR VEHICLE FUEL ❑ 4 OILB, C to REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ' UNLEADED ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT1b PREMIUM ❑ 4 GASAHOL ❑ ❑ ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXFS A,8,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 D E WALL 3 SINGLE WALL WITH EXTERIOR LINER El95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 99 OTHER ❑ ®. TANK 1 BARE STEEL F-12 STAINLESS STEEL ❑ 3 FIBERGLASS [7] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrimaryTarik) 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLr- LINING C.INININIGR 5 GLASS LINING ❑ 6 UNLINED L:� NKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV, PIPING INFORMATION CIRCLE A IFABOVEG UNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 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 f 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 8 CONCRETE A U 7 STEE 1COATING A U 8 1DO% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 G ZEO STEEL A U 10 CATHODIC PR ONU 9 UNKNOWN A U 99 OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 MONTGRING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK U 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORINGAUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN 99 OTHER VI,TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME {PRINTE©6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# !]��(p y 7 STATE I.D.# ❑ qP I IJ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE -5`3 FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, FORbIXi49-R5 0 � VI