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STATEOFCAUFORNIA o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ~ ❑ 7 PERMANENTLY CLOSED DNS MAR;ITEM Y ❑ EW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 8 TANK REMOVED ON2 INTERIM PERMIT4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSUREDBACILITYNAME WHERE TANK IS INSTALLED: �� . LL2 , _ `- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 8. MANUFACTURED BY: A. OWNERS TANK 1.0.8 �� u D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOIDAYNEAR) ILTANKC ENTS IFA-113MARKED.COMPLETE ITEM C. aREGULAR 3 DIESEL g AVIAT ON GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. / C. UNLEADED e 4 GASAHOL ❑ 80 EMPTY rL-� 1 PROIXICT 1b PREMIUM ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ ❑ UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME 6 SUBSTANCE STORED C.A S.i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,ANDC,ANOALLTHATAPPLIES INBOX D AND Y6OUF7BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN A. TYPE OF SYSTEM 2 INGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARESTEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE F-18 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP MATERIAL r7 (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 0 LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN 99 OTHER LINING IS UNWG MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO D.CORROSION ❑ 1 �ME WRAP ❑ COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODK:PROTECTION 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CI LL A IFA80VEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEMTYPE A U CSUCT A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U CSIN A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 lARE9TEEC A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEELWICOATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 UNE TIGHTNESS TESTING ❑ MOLrron H5TIT G KL ❑99 OTHER V.TANK LEAK DETECTION F1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING C:] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING C:] 7 INTERSTITIALMONITORING ❑ 91 NONE E] 95 UNKNOWN E:] 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LASTUSEQ(MdOAV/YR) 2.ESTIMATED QUANTITY OF (,./,1 o v LOINS 3 WAS TAN FILED WITH YES ❑ NO SUBSTANCE REMAINING C V THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINlEG 431G.TV LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# d4o TANK# STATE I.D.# ® = _fl u I FIKU PERMIT NUMBER PER MIT APPROVED BYIDATE i (✓PERMIT EXP TION DATE 3,"3 6�y�yj FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR08M8A5 ;K �Ilgl, Isbw� PINr"tY 7�tC�.��-t�.�3