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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 01 UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B �` y; COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT S CHANGE OF INFORMATION 7 PER�,7 SITE TEMPORARY TANK CLOSURE ❑ 8 TAN DBA OR FACILITY NAME WHE RE TANK IS INSTALLED: y I. TANK DESCRIPTIONCOMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.III B. MANUFACTURED BY: C. OATE INSTALLED(MO/DAY/YEAR) _ D. TANK CAPACITY IN GALLONS: Ii.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. Cto REGULAR 3 DIESEL UNLEADED❑ 2 PETROLEUM ❑ 80 EMPTY � 4 GASANOL 1 PRODUCT Q lb PREMIUM L�Jj ❑ 6 AVIATION GAS ❑ ❑3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED 5 JET FUEL 7 METHANOL ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW} D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.13,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 95 UNKNOWN ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 1 MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ff7 ALUMINUM # ❑ 8 100% METHANOL COMPATIBLE WlFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER i ❑ t RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR PV 5 GLASS LINING ❑ 6 UNLINED ' LINING ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP {{ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 4 FIBERGLASS REINFORCED PLASTIC ! ❑95 UNKNOWN 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 ) i A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U 9t N A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) ERGLASS PIPE CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING PROTECTION A U 9 GALVANIZED STEEL A (J 10 CATHODIC PROTECTION 0°6 METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN THER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING s MONITORIN9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK �2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING a 91 NONE a 95 UNKNOWN a 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH GALLONS INERTMATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# PERMIT NUMBER PERMIT APPROVED L BYIDATE / PERMIT EXPIgATION DATE ' THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FO HAS BEEN FILED. FILE THIS FORM WITH�,�LOCA IMPLEMENTING THE UNDERGROUND STORAGE TA GULATIONS G� FORM 8 (72.91) i { FOROM48•RS