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STATE OF CALIFORNIA AWS 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 ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY OSED ON SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE O.- DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (p I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# &� B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 7 D. TANK CAPACITY IN GALLONS: II.TANKCONTE S IFA-1 IS MARKED,COMPLETE ITEM C. 1a REGULAR DIESEL A, 1 MOTOR VEHICLE FUEL � 4 OIL B. C• ❑ UNLEADED ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY PRODUCT 1b PREMIUM ❑ 4 GASAHOL 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 UNLEADED EADED 99 JET L OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.ar 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 SYSTEMSINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F—] 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM F--] 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR LINING F--] 5 GLASS LINING UNLINED E-195 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �ONKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 'V UNKNOWN A U 99 OTHER D. LEAK DETECTIONTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK NVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# Z VVVI VF7 4 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 FORM B (12-91) / • � `\ � F B-R6