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• Q ' STATE OF CALIFORNIA /-} / t 9 STATE WATER RESOURCES CONTROL BOARD l UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B G COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. REGULAR C. aUNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANE LY CLOS SITE ONE ITEM LIG' - INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK RE O VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A- NT (mac iJf, Z 0(� 7 IMINUM El 1009/ METHANOL COMPATIBLE W/FRP I TANK nFSCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER A. OWNER'S TANK I. D.9 B. MANUFACTURED -BY: REGULAR C. aUNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: Q �J II TAMWrCWTFNTS IFA-1LCMARKFD-COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. REGULAR C. aUNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lbUNLEADED ❑ 5 JET FUEL ❑ PREMIUM 7 METHANOL ❑ 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 CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D IV_ PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE 1111IJOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SINGLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDEn 7 IMINUM El 1009/ METHANOL COMPATIBLE W/FRP (Primary Tank) F--]9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING n/EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR 5 GLASS LINING 6 UNLINED 11 UNKNOWN 99 OTHER LINING A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 5 UNKNOWN A U IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? IS YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 L WRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 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 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 U 5 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 ST W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL MONITORING 99 OTHER ❑ V TANK I FAK nFTFCTION I� 1 VISUAL CHECK ❑ 2INVENTORY 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE 2 (PRINTED & SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # I TANK # UL) STATE I.D.#L G l U O v G 4 (/T0 PERMIT NUMBER < 00T -57 PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B 19-901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. _. FOR0034B•R4