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w e STATE OF CALIFORNIA = STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT E3,4CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: F E- Q n I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.0 03 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY)YEAR) D. TANK CAPACITY N GALLONS: D 11.TANK C ENTS IFA-11SMARKED,COMPLETEITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• UNLEADED e 7 DIESEL ❑ S AVIATION GAS 1 ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ Ib PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE N ITEM 0. BELOW) D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED O A.S.0: 111. TANK CONSTRUCTIOR MARK ONE ITEM ONLY IN BOXES A R.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I LE WALL ❑ 3 SINGLE WALL WRH EXTERIOR LINER E:] 95 UNKNOWN SYSTEM 2 HOLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFISERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100'% METHANOL COMPATIBLE WIFRP (Pdmuy Tank) ❑ 0 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNNG ❑ 3 E LINING ❑ 4 PHENOLIC LINING C.IN ❑ 5 GLASS LINING LININGINING ❑ 5 UNLINED UNKNOWN ❑ W OTHER IS LINING MATERIAL COMPATIBLE WITH 100x.MEDUWOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2,006NG ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UN104OWN 99 OTHER IV.PIPING INFORMATION A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U1 SUCTI A U 2 PRESSURE A U 3 GRAVITY p U 90 OTHER S. CONSTRUCTION A U 1 SIN A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 90 OTHER C. MATERIAL AND A U BAREST L A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING 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 D. LEAK DETECTK)N ❑ 1 AUTOMATIO LINE LEAK DETECT;!R ❑ 2 LINE TIGHTNESS TESTING 390 OTHER _. MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED( Yi 2.ESTIMATED QUANTITY Of 7.WAS TANK FILLED WITH (7 SUBSTANCE REMAINING f7 GALLONS INERT MATERIAL? YES ❑ No THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IVNxTEO a 516NATYRE) LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# = --n-y- PERMIT NUMBER PERMIT APPROVED BYIOATE PERMIT EXPIRATION DATE FORM B (9 9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. /� fOFONi9.N