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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: T1D J.- 1. . -I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. R O 0501.1 q 3 3 B. MANUFACTURED BY: C. DATE INSTALLED (MOIDAY/YEAR) H 3 DIESEL ❑ 6 AVIATION GAS u 4 GASAHOL ❑ 2 PETROLEUM D. D. TANK CAPACITY IN GALLONS: II TAAIV P/MRCAITC .m. of rac rtcuc 1b PREMIUM UNLEADED VM G ♦��V rQ 4 � O �a O 7 PERMANENTLY C O 8 TANK REMOVED A ❑ 1 MOTOR VEHICLE FUEL 4 OILB. F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN C. ❑ la R EADED ULAR H 3 DIESEL ❑ 6 AVIATION GAS u 4 GASAHOL ❑ 2 PETROLEUM ❑ BO EMPTY B. 1 PRODUCT 1b PREMIUM UNLEADED ❑ 7 METHANOL ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 5 CONCRETE ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 0 BRONZE ❑ 10��1111LLLGKKKKAVVVVLVANDED STEEL C. A. S. R: 111 TAkIV y`nAICTO"f%TV1AI ... uPnrcee P Bunn eunell TWATAPPI Ie91NPnYn A. TYPE OF ❑ 1 LISLE WALL LALE F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. 1 BARE STEEL ❑ 2 STAINLESS STEEL F-]3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/F RP (Primary Tank) ❑ 0 BRONZE ❑ 10��1111LLLGKKKKAVVVVLVANDED STEEL ❑ 85 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE ❑ 1 RUBBER LINED ❑�D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 96 UNKNOWN ❑ 9a OTHER LINING PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODK:PROTECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— 99 OTHER V4f&"ZZ D. CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION © B/ NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A6711 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(p SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U W 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 COMPPATIBLEE (FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODK:PROTECTION A U 95 UNKNOWN A U 99 OTHER V4f&"ZZ D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MOTFI NRORINGL ❑ OTHER '.TANK L AK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 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 ❑ a I /LL SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED e SIGNATURE) 3ENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW W hL, COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# 4�Qw � BEI l R PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS IS 90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. i1--a;k_ Q,/ � FOR0m4644