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P STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 RMANENTLV CLOSED ONSITE MAR;ITEM LY ❑ 1 NEW PERMIT ❑ ❑ ON ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIIT ❑ e TEMPORARY TANK CLOSURE 8 TANK REMOVED DBAACILITYNAMEWHERE TANK IS INSTALLED: (J�e9 / a p I w-." I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: A. OWNER'S TANK I.D.a D. TANK CAPACITY IN GALLONS: vor C. DATE INSTALLED(MOIDAWYEAR) iiN:m IFA-11S MARKED,COMPLETE IT C. 1a REGULAR 0 3 DIESEL ❑ 7 AVIATIMETHANOLAS EHICLE FUEL ❑ 4 OIL 8. C. ❑ UN ADED 4 GASAHOL UM ❑ EM UM BO EMPTY 1 PRODUCT ❑ 1 UNLEAIDEO ❑ 5 JETFUEL ❑ L PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 9g OTHER (DESCRIBE IN ITEM D. BELOW) KED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ 99 OTHER SYSTEM ❑ INGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ FEBARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP 5 CONCRETE9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING5 GLASS LINING 6 UNLINED ❑ 95 UNKNOW99 OTHER ING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ N07/ O ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CISQUEAIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U<eSWGLEWAL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 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 8 CONCRETE A U 7 STEELW/C A U B 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION95 UN OW A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING 9 MONITOflING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 DOZEMONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION ( IOAYIVR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 1.ESTIMATED DATE-Ak�7"/ SUBSTANCE REMAINING C) GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# j77JGlL� STATE I.D.# M] = F;qxjjjFiId FETTIM PERMIT NUMBER PERMITAPPROVED BY/DATE PERMIT EnTION D //z FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. t FOAOWB 0 Fc,c ��