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a G \� C. DATE INSTALLED (MO/DAY/YEAR) 1 ' \ STATE OF CALIFORNIA PRODUCT ❑ 1b PREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL pebouA 'y ° STATE WATER RESOURCES CONTROL BOARD ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 'a B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) MARK ONLY❑ NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT CLOSED 0 SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REM ED D/J v DBA OR FACILITY NAME WHERE TANK IS INSTALLED: V,Ij �j-f� -T (� /`(; n ❑ 2 ALKYD LININGV95 OXY LINING 1 TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN C. INTERIOR ❑5 GLASS LINING A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) 1 D. TANK CAPACITY IN GALLONS: II TAMI(r`r1NTFMTS ICA_l I¢MARI(Fn CnMPI FTFITFMC_ A t MOTOR VEHICLE FUEL ❑ 4 OIL B. C. aREGULAR UN EADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 GASAHOL ❑ 2 PETROLEUM F—]80 EMPTY PRODUCT ❑ 1b PREMIUM ❑ 7 METHANOL 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 OF SUBSTANCE STORED C. A. S. #: III TANK r 0NSTRI ICTION MARK nNF ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D A. TYPE OF❑� 1 OUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SINGLE WALL ❑ 1 BARE STEEL F72 STAINLESS STEEL ❑ 3 FIBERGLASS 7]4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ ❑ MINUM �95 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑9 BRONZE ❑ 10 GALVANIZED STEEL KNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LININGV95 OXY LINING F—]4 PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING F—]6 UNLINED NKNOWN ❑ 99 OTHER LINING A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION e5 UNKNOWN A U IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO vy INTERSTITIAL 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TE G ❑ 9 MONITORING ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING❑ 3 INYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV_ PIPING INFORMATION CIRCLE A IF ABOVEGBOUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH (j 95 UNKNOWN A U 99 OTHER A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL AND 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 e5 UNKNOWN A U 99 OTHER D. LEAK DETECTION vy INTERSTITIAL 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TE G ❑ 9 MONITORING ❑ 99 OTHER 1! TAKIV 1 GAI( nl:TFrTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4 TOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 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 ❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? 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 LD. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW f/ joa jl COUNTY # JURISDICTION # FACILITY # 3 (Q TANK # 0D1 STATE I. D.# 5 1 p Q 10 1 U p/ 14-0r)a PERMIT NUMBER Q G v PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE GnAM R IQ_Qnl THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. '� 1 FOR00348-144