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II STATE OF CALIFORNIA ts„oAoe �`L^ STATE WATER RESOURCES CONTROL BOARD sy a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED; 3 Q Get I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D, B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED, COMPLETE ITEM C. A u 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGU R 3 DIESEL ❑ 6 AVIATIONGAS 2 PETROLEUM EMPTY 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL ❑ ❑ ❑ UNLEADED ❑ 5 JETFUEL ❑ i ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) I D, IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # ; III- TANK CONSTRUCTIOW MARK ONE ITEM ONLY IN BOXES A. B, AND C, AND ALL THAT APPLIES IN BOX D AND DO BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF E::] I SYSTEM INC LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER { 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B, TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) O 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER r ❑ 1 RUBBER LINED ❑ 2 KYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR F 5 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER I LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES — NO _ ❑ 2 GATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION F-] 1 POLYETHYLENE WRAP PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E, SPILL AND OVERFILL SPILL CONTAINMENT WSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CL IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1Njueflar 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 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 8 100% 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 ❑ 3 MONITORING ❑ 99 OTHER TERSTITIAL V- TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITOFtING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATERMONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1 . ESTIMATED DATE LAST USED (MOIDAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 IPRINTEO a 3IONATUREI LOCAL AGENCY USE ONLY THE STATE ID, NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION # FACILITY # TANK # 57ta"- l3 STATE I . D .# 3 I PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE j FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN 11 t FOROWdbR5 1.