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V„ P STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD r� UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B , Cell.qF N'F COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERWT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 0 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 'X B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 30 1, TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A, OWNER'S TANK I.D.a S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) +D, TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS A MOTOR VEHICLE FUEL ❑ 4 7EMPTY B. C• UNLEADED ❑ 4 GASAHOL 1 PRODUCT ❑ 1b PREMIUM ❑ 7 METHANOL ❑ PETROLEUM ❑ 80 UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 ❑ 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 BOXES A.B.AND C,AND ALL TF4AT APPLIES IN BOX D AND E ❑ 1 ®LE WALL F--] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ SYSTEM ❑ 2 SIN E WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARES EL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP MATERIAL ❑ 5 cDNCRET (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINE ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL CO A718LE WITH 10096 METHANOL? YES— NO� 1 POLYETHYLENE W P F] 2 COATING ❑ 3 VINYL WRAP ❑� 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHODIC PRDTECTI F195 UNKNOWN 99 OTHER 91 NONE ❑ ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT I STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFAS EGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 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 A U 1 BARE STEEL A 2 STAINLESS STEEL A 'U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U CONCRETE A U 7 STEEL WI COATING A U 8 100'/ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 1 CATHODIC PROTECTION A U 95 UNKNOWN st A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ VADOZF MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 iNTERSTiTIALMONITORING F791 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DAT LAST USED( GALLONS INERT MATERIAL M lDAY1YR) 2.ESTIMATED QUANTITY OF S.WAS TANK FILLED WITH � � SUBSTANCE REMAINING ? YES [7] NO THIS FORM HAS BEEN COMPLETED FINDER PENALTY OF PERJURY,AIII TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 4STATE I.D.# PERMIT NUMBER ERMIT APPROVED BY/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 Y OCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS /,3f FORM B (12.91) - ✓ `G, .�% I FOR0034B-R6