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b'i,lf r STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;, ' $ t COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 09 ITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ® B TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED +5 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ` �S �` C,i( ; ;vt. . I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. B. MANUFACTURED BY: C. DATE INSTALLED(MO1DAYNEAR) D. TANK CAPACITY IN GALLONS: II,TANK C NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A LCfl MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a R ULAR 3 DIESEL ❑ 6 AVIATION GAS O L 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ 1bUN EAIUM L❑ 5 ET FU E ❑ 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑✓�2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4s: ` III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,R,AND C,AND ALLTHAT APPLIES IN BOX D AND E/ A. TYPE OF F7 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER g5 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK Imo❑ 1 BARE STEEL F7] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC MATERIAL 0 5 CONCRETE 0 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 0 B 1001% METHANOL COMPATIBLE W1FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ©`95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C,INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ®.45 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOT 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 IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A(Y__�5 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 RARE 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 Wl COATING A U 8 10091 METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 (MONITORING L 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK F❑ 2 INVENTORY RECONCILIATION ❑1 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING 6 TANK TESTING 0 7 INTERSTITIAL MONITORING C 91 NONE 0 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2,ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑� NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED&SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK is STATE I.D.# 2 2 Pa l PLRMITNUMBER I PERMIT APPROVEDBYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED, FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOAM R (12-91) F01100946-136 f