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SVURf,ES STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B aT �, � ` COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. W, MARK ONLY ❑ 1 NEW PERMIT ❑ RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT V AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED ♦.� , DBA OR FACILITY NAME WHERE TANK IS INSTALLED: of=`Q -Lo V I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY NKNOWN A. OWNER'S TANK I.D.# 3 J B. MANUFACTURED BY: � C. DATE INSTALLED(MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: le) eCJ II,TANKCO ENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULAR ❑ 3 DIESEL A. / 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED E:1 5 JET FUEL F--] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C q S #: 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 ❑ 1 OUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK F-] 1 BARE STEEL 712 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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED LKYD LINING F-] 3 EPDXY LINING F-] 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING [e2 NLINED F-] 95 UNKNOWN ❑ 99 OTHER LINING V% IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES-!L--NO— D. NO D.CORROSION ❑�Z5 LYETHYLENE WRAP F-] 2 COATING F-] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION THODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN a 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GR DOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 9_-,l SUCTION AP ESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A,Q FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9LVANIZED STEEL U 0 CATHODI OTECTION A U 95 UNKNOWN A U 99 OTHER IAI D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DE 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION j�§�rTAAINK UAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING [:�::] 5 ND WATER MONITORING TESTING INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFO'hMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATE QUANTITY OF 3.WAS TANK FILLED WITH S BSTA E REMAINING GALLONS INERT MATERIAL? YES E:] NO ❑ THIS FORM S BEEN COMPLETED UNDER EN OF PERJURY ND TO THq BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT AP A T'S NAME DATE 7 LOCAL AGENCY/USE ONLY THE STATE I.D.NUMB COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 1 t OS )7 STATE I.D.# m ❑m 10 S s Is, PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE -S d4 113 ll FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348-R5