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"�suP"cel STATEOFCALIFORNIA ,�••�'+: STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR H TANK SYSTEM, MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLO ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE '❑ 8 TANK REMOVED i DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# os B. MANUFACTURED BY: C. DATE INSTALLED(MO'DAYNEAR) f 0. TANK CAPACITY IN GALLONS: /0) L1"� ILTANK ENTS FA-11SMARKEO.COMPLETEREMC. 1 MOTOR VEHICLE FUEL ❑ A OIL la REGULAR 3 DIESEL A. B' C' UNLEADED ❑ B AVIATION GAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT a 113 RNL ADEMIUM 5 J�F 11 ❑ 7 METHANOL ❑ 3 CHEMICALPROOUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. SELO'N) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED O A.S#: III. TANK CONSTR ON MARK ONE ITEM ONLY IN BOXES A.EL AND C.AND ALL TIUT APPLES IN BOX O AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 9D OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL [Rr3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP (PNmny Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED ❑ 96 UNKNOWN ❑ N OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP =Llf< FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ,❑ 91 NONE ❑ 95 UNKNOWN ❑ 90 OTHER E SPILL AND OVERFILL SPILL CONTAWMENT 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 I SUCTION A g2 PRESSURE A U 3 GRAVITY A U N OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 aARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVWYL CHLORIDE(PVC)A A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION F31 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINETIGHTNESSTESITNG ❑ MONOORNG ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK L�I j INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING a A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING �r'A /7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOAOAY/YR) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERML? T741S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNANRM r11 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOWry COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D. z I z > > I I PERMIT NUMBER PERMIT APPROVED BYIOATE PERMIT EXPIRATION DATE �IlicZh.L� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH T (CAL AGENCY IMPLEMENTING THE UNDERGROUND STO' --TANK REGULATIONS FORM a (t2.91) FOROON&R6