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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B :n , \` � CPt iaOPPa COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 5 CHANGE Of INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 TANK REMOVED Q EDBA ONLY O ❑ q AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE TEM 2 INTERIM PERMIT RFACILITY NAME WHERE TANK IS INSTALLED: aaI u I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY: A. OWNER'S TANK I.D.# r /1 D. TANK CAPACITY IN GALLONS: (/ C. DATE INSTALLED(MO/DAYIYEAR) II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. 1a REGULAR O 3 DIESEL ❑ 6 AVIATIO]GAS C. ❑ UNLEADED ❑ 4 GASAHOL 7 METHA A i MOTOR VEHICLE FUEL 4 OIL B. IbPREMIUM ❑ 2 PETROLEUM 90 EMPTY ❑ 1 PRODUCT ❑ UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ C. OTHER (DESCRIBE IN ITEM D. nI C.A.S.# D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED .moi III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.B,AND U.AND ALLTHAT APPLIES IN BOXD AND ❑ ❑ 95 UNKNOWN ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER A. TYPE OF ❑ 99 OTHER SYSTEM �2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC BARE STEEL ❑ 9 100% METHANOL COMPATIBLE W/FRP B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM MATERIAL ❑ 99 OTHER (Primary T#nk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 3 EPDXY LINING 4 PHENOLK; LINING ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ ❑ C.INTERIOR ❑ 5 GLASS LINING Xfi UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES N ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS NO PLASTIC D.CORROSION ❑ 1 NO— POLYETHYLENE WRAP ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE a U 1 sucTloN A U 2 PRESSURE A 1 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 U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 5/COATING UNKNOWN A U 891000%%THERMETHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING O AUTOMATIC TANK GAUGING 5 GROUNDWATER MONITORING UNKNOWN 99 OTHER ❑ fi TANK TESTING ❑ 7 INTI RSTITIAL MONITORING 91 NONE VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES ❑ N3 2.ESTIMATED DO AN OF GALLONS INERT MATERIAL? 1.ESTIMA DDA LAST SED(MO/DAY/YR) SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A D TO THE BEST OF MY KNOWLEDGE,DIS RUE AND CORRECT APPLICANTS NAME (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION# FACILITY# STATE I.D.# C� o E:l PERMIT NUMBER PERMITAPPROVED BY/OATS PERMIT EXPIRATION DATE THIS FO EMTHISSFORM WITHATHENLOCAL AGENCYIED BY A IMPLEMENTING THE UNDERGROUND NDERGROUND STORAGE TANK REGULATIFILED. FILONS • FOR69348-116 FORM B (12-91) 0