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//ttMM SUURCES STATE OF CALIFORNIA °? STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLCSWO 5'hTE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,Za y I. I ANK UtbUKII' I IUN COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: I. 1 ANK N I tN 1 J IFA -1 IS MARKED, COMPLETE ITEM C. 0 A. 1 MOTOR VEHICLE FUEL ❑ 4 OILg, ❑ 1 OUBLE WALL C a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEADED ❑ 4 GASAHOL 80 EMPTY E72 PETROLEUM F-]1 PRODUCT UNLEADED ❑ 5 JET FUEL 0 7 METHANOL ❑ 1bUN ❑ 3 CHEMICAL PRODUCT 0 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. A. S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPI IFS IN ROX D AND F A. TYPE OF ❑ 1 OUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VA TEDTANK) ❑ 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 1009/ METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING 7 STEEL W/ COATING A U ❑ 5 GLASS LINING 6 UNLINED ❑ 95 NC ❑ 99 OTHER LINING p U 1 CATHODI ROTECTION p U 95 UNKNOWN A U 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ No D. CORROSION ❑1 LYETHYLENE WRAP F–]2 COATING F—]3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION rV�< CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) % v 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 P ESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 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 FI ERGLASS PIPE CORROSION A U 5 ALU INUM A U CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION p U 9 ALVANIZED STEEL p U 1 CATHODI ROTECTION p U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL ❑ 99 OTHER MONITORING V. TANK LEAK DETECTION ❑ VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 UND WATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN vl HER VI. TANK CLOSURE INFOR ATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO E�l SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAL F PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT AP ANT'S NAME// DATE r ✓ FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION /I 10 M A, UNLESS A CURRENT FORM A HAS BEEN FILED. �.-- FOR00348•RS F�� LOCAL AGENCY USE ONLY THE STATE I.D. NUMBE OM SED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# PERMIT NUMBER PERMIT APPROVED B j i 1® , PERMIT EXPIRATION DATE r ✓ FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION /I 10 M A, UNLESS A CURRENT FORM A HAS BEEN FILED. �.-- FOR00348•RS F��