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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B w u. -e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c-0'' ol~ MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL P€RM17 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEb DBA OR FACILITY NAME WHERE TANK IS INSTALLED: T7 o 0 a Gn CC5 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# — �r B. MANUFACTURED BY: C. DATE INSTALLED(MOJOAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1aUREGULNLEAR ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM 80 EMPTY 1 PRODUCT 11�PREMIUM ❑ 4 GASAHOL I—I 7 METHANOL EADED ❑ 5 JET FUEL El 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(Al)IS NOT 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 D AND E A. TYPE OF ❑ 1 DOUB E WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK F71 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL S UNKNOWN ❑ 99 OTHER F71 RUBBER LINED F—] 2 ALKYD LINING F73 EPDXY LINING F74 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED NKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 190% METHANOL? YES_ NO� D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONENKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR} OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GR DOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 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 WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GAL IZED STEEL A U 10 CATHODIC PROTECTION A trg UNKNOWN A U 99 OTHER D. LEAK 'DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING L 3 I TERS11 IAL MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING E:J MATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN F1 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOYDAYYR) ESTIMATED QUANTITY OF S.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERT MATERIAL? YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPDCANTSNAME r (PRINTED&&GNATURE) LOCAL AGENCY USE ONLY THE STATE I.D,NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# b F'4c U L'f 7 STATE I.D.# F-TF�-N PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 034B-R5