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�co�^ e r STATE OF CALIFORNIA a a STATE WATER RESOURCES CONTROL BOARD s�� , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �4monY�n COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Eo8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I,D.# t B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAWYEAR) 46-k, D. TANK CAPACITY IN GALLONS: 6 000 IL TANK CONTENTS IFA-0ISMARKED,COMPLETEITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1eUNLEADED REGULAR F-1 3 DIESEL ❑ g AVIATION GAS 4 GASAHOL ❑ 2 PETROLEUM El Bo EMPTY 1 PRODUCT ❑ 1bUNLEADED ❑ 5 JET FUEL E::] 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 96 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM 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 ALLTHAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL [-] 3 SINGLE WALL WITH EXTERIOR LINER E:] 95 UNKNOWN SYSTEM V2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL V195 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑N/3 EPDXY LINING [:] 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED Li 95 UNKNOWN ❑ 99 OTHER LINING LS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VE9_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION ❑ 91 NONE V UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATIOU CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A VI 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 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ep96 UNKNOWN A U 99 O ER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3IONRORINGL 99 OTHER u,�(/. V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ny AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATEDDAE L ;,USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF I- 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING �NA_ 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 (PRNTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# F3-1?] 9 7 GA/Gr39 PERMIT NUMBER PERMIT APPROVED BYIDATE 0 / / FORM B (9.90) - THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. "/FO//RD^m/)19w �rr'1 ✓