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• p4 u" �3 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH T SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS O SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 11-11 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.i (p B. MANUFACTURED BY: v C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL g, C to REGULAR 3 DIESEL A. UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM SO EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 ET FUEL L 7 METHANOL F-13 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE U EADE ED F-1 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.71 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 UBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F7 2 STAINLESS STEEL F7 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F-] 6 POLYVINYL CHLORIDE 7 ALUMINUM a 8 1009/6 METHANOL COMPATIBLE W/FRP (Primary Tank) E::] 9 BRONZE 0 10 GALVANIZED STEEL 95 UNKNOWN a 99 OTHER 71 1 RUBBER LINED 2 ALKYD LINING E::] 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR F-1 5 GLASS LINING 6 UNLINED 1:1 95 UNKNOWN El 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP F-1 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEUNKNOWN E] 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 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 0 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A V 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 G LVANIZED STEEL A U 10 CATHODIC PROTECTION A< 3 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION FE-- 1 VISUAL CHECK INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN E::] 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 2 t d PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 11-3- THIS -3_THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS \ 1Fti00BYB FORM B (12-91)