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o _ -- : STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B e . . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION OF 7 PERMAN Y C ITE ONE ITEM ❑ 2 INTERIM PERMIT f-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK RE OVE o OBAOR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D, a B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) (✓ D. TANK CAPACITY IN GALLONS: O - Ile TANK COP116NTS IFAAISMARKED.COMPLETEITEMC. A EKI MOTOR VEHICLE FUEL ❑ 4 OILB. C. aREGULAR 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT Ib PREMIUM 4 GABAHOL 7 METHANOL ❑ UNLEADED JL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E::] 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED - C. A. S. a : III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, 8. AND C, AND ALL-THAT APPLIES IN BOX AND A. TYPE OF ❑ 1 ,P009GEWALL. ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SIN WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10096 METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 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 Eaomo�UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES _ NO_ D, CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 ' VI L WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E::] 91 NONE UNKNOWN 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR 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 U 95 UNKNOWN A U 99 OTHER N\ 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 W/COATING A U. 8 10016 METHANOL COMPATIBLE W/FRP 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 MONRORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 1 ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 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 )) (PRINTE0691GNATURM // LOCAL AGENCY USE ONLY THE STATE IA. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW L( — i / CN JURISD # FACILfTYu TANK # L_C�LJ STATE I . D .# 0 p 2� PERMIT NUMBER PERMIT 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. PN�FOMXR6 FILE THIS FORM WIT CAL AGENCY IMPLEMENTING THE UNDERGROUNDS GE TANK REGULATIONS FORM B (12-91 )