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STATE OF CALIFORNIA u STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FORE H TANK SYSTEM. MARK ONLY Q 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ^ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE k OBA OR FACILITY NAME WHERE TANK IS INSTALLED: 90 3 /Yj I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN b'A t01 A. OWNER'S TANK 1.0.t u i 3. MANUFACTURED BY: C. DATE INSTALLED(MO/OAY/YEAR) 0. TANK CAPACITY IN GALLONS: II.TANKCO NTS IFA-1 IS MARKED.COMPLETE ITEM C. p t MOTOR VEHICLE FUEL ❑ a OIL & C. GUUR — 3 OIESEL g AVIATIONGAS —� UNLEADED 4 GASAHOL ❑ 2 PETROLEUM Q 80 -4PTY 1 PRODUCT ❑ Ib PREMIUM �� ❑ 7 METHANOL UNLEADED n 5 JET FUEL ED 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN j-7 2 WASTE ❑ 2 LEADED LJ 99 OTHER (DESCRIBE IN ITEM 0. 9ELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.x: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.3.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF ❑/1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER C'I 95 UNKNOWN SYSTEM =— 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ��I 99 OTHER B. TANK ❑ 1 BARE STEELr lI 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ IO GALVANIZED STEEL ��tOWN (❑ 34 OTHER 1 RUBBER LINED ❑ 2 ALKYD LNWG 3 EPDXY LINING 4 PHENOLC LINING C.INTERIOR FI 5 GLASS LINING u 8 UNLINED UNKNOWN ❑ 99 OTHER UNING IS LINING MATERIAL COMPATIBLE WITH 1,00% METHANOL? YES— NO_ 0.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE JNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION ECUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF A80VE GROUND OR U IF UNDERGROUND.SOT14 IF APPLICABLE A. SYSTEM TYPE A/0 :1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 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 8 CONCRETE A U 7 S AM COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTIONU UNKNOWN A U 99 OTHER D. LEAK DETECTION C:] 1 AUTOMATIC LINE LEAK DETECTOR C 2 LINE TIGHTNESS TESTING ❑ 3 ypNR TITIA 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAOOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING B TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VL TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY/YR) I Z ESTIMATED QUANT17Y OFI 3.WAS TANK FILLED WITH 1 SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES �J NO 1 THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (plumm d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE LO.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ` COUNTY* JURISDICTION s FACILITY x TANK x O�[) STATE L.D. PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMIT EXPIRATIQN DAT FORM 3 (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED., n _ FORoas<eas