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. • • 40V t STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD w !2 u o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B /i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ ] PERMANENTLY CLO ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a TANK REMOVED MARK ONLY O 1 NEW PERMIT ❑ 6 TEMPORARY TANK CLOSURE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PE0.M1T YjdALLh DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY: A. OWNER'S TANK I.D.# /)boo N o D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAY%AR) II.TANK CONTENTS FAIISMARKEO.COMPLETEITEMC. 1a REGULAR ❑ 3 DIESEL ❑ IAVIATIONGAS MOTOR VEHICLE FUEL ❑ 4 OIL B. ,,��yy C' ❑ UNLEADED ❑ 4 GASAHOL 7 METHANOL A. ❑ 80 EMPTY PRODUCT ❑ 1bUNL AIUM DED ❑ 5 JET FUEL ❑ ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) C.A.S.#) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED -------------- III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX O AND ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN 1 DOUBLE WALLA. TYPE OF ❑ SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 1 BARE STEEL 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ MATERIAL ❑ ❑ s9 OTHER (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ B5 UNKNOWN F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER ❑ LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— = ES_ — D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION M' E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND.BOTH IFAPPLICABLE A. SYSTEMTYPE U 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 U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 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 A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER PROTECTION A U 9 GALVANIZED STEEL A U NTERS 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TE STING ❑ 3 MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING X 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WASTANKFILLEDWITH vas NO� 2.ESTIMATED QUANTITY OF GALLONS INERT MATERIA L? 1.ESTIMATED DATE LAST U E (MOIDAYf/R) SUBSTANCE REMAINING TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT THIS FORM HAS BEEN COMPLETED UNDER PENAL APPLICANTS NAME (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION# I L_�FACILITY# STATE I.D.# L J�U rl= i. PERMIT NUMBERLLL PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE REGULATIONS FaRnmee-Rs FORM B (12-911 0