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STATE OF CALIFORNIA V •.. t _._ STATE WATER RESOURCES CONTROL-BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B - . y: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED ONSITE ONE REM Q 2 INTERIM PERMIT F-� 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE EX 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED:S��Z I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 10 A. OWNER'S TANK I.D.• 1 B. MANUFACTURED BY: U p, C. DATE INSTALLED(MO/DAY/YEAR) V k)LL 12UL&I O. TANK CAPACITY IN GALLONS: )(9,000 II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ 1aREGULAR UNLEAD- H3 DIESEL 6 AVIATION GAS 4 GASAHOL O 2 PETROLEUM O 80 EMPTY i PRODUCT it PREMIUM ❑ 5 JET FUEL ❑ 7 METHANOL UNLEADED 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.A.S.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 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM O 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL F--j 3 FIBERGLASS f--j 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE F--j 7 ALUMINUM F-] 8 100%6 METHANOL COMPATIBLE W/FRP (PrimaryTank) 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER O 1 RUBBER LINED � 2 ALKYD LINING O 3 EPDXY LINING E] 4 PHENOLr- LINING C IrLININIGR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING F-J 3 VINYL WRAP F-] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN a 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR)(„ i! IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION q Q 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U t SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AQ 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 AQ U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 MONITORING 99 OTHER V.TANK LEAK DETECTION L 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING [:] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING O 91 NONE Ilul 95 UNKNOWN a 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES EDE THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE Q (PRINTED 6 SIGnE) 7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# m = I = PERMIT NUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATION DATE THIS FORM MUST BE ACCOMPANI[ 'BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH CXL AGENCY IMPLEMENTING THE UNDERGROUND SE TANK REGULATIONS FORMS (12.91) To FOR00348-R6