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5°V" e STATE OF CALIFORNIA �.. c' t t STATE WATER RESOURCES CONTROL BOARD i_ ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B w u: 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERM CLOSED ON E�{�►'� ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (_ I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN J A. OWNER'S TANK I.D.X B. MANUFACTURED BY: A\'\0C. DATE INSTALLED(MO/DAY/YEAR) Vh ��C D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. lZSI 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ la REGULAR G "� 3 DIESEL A. ❑ 6 AVIATION GAS 4 GASAHOL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ ❑ 7 METHANOL ❑ UNLEADED L 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E:] 2 WASTE E::] 2 LEADED ❑ 99 JOTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED e C.A.S.A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF L�?-1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK �k 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% 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 ❑ 95 UNKNOWN Fm;�'t 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO 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 IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 62 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 0 MONRORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE r❑�95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(M DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? E] ❑ HIS FORM HAS hEEN COMPL-eTED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE�� (PRINTED 8 SIGNATURE) . f / /—3 1 —2 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / / COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.#a3 i5 ❑ a 3 1 5 3 ) D 3 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE I THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST'"".GE TANK REGULATIONS FORM B (12-91) FOR0034121-4