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„-. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH NK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN Y CL TE ONE REM ❑ 2 INTERIM PERMIT ❑ l AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE ❑ 9 TANK REM VED G DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.t 8. MANUFACTURED BY: C. DATE INSTALLED(MOIOAYF/EAR) / 7-70/ D. TANK CAPACITY IN GALLONS: !' Q II.TANK CONTENTS IFA-1 ISMARKEO,COMPLETETTEMC. ,L 1 MOTOR VEHICLE FUEL ❑ A OIL B. C. ❑ I&ArGULAA3 DIESEL ❑ e AVWTIONGAS UNLEADED ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT 1bPREMIUM A GASAHOL ❑ ❑ 7 CHEMICAL PRODUCT 95 UNKNOWN El7 METHANOL UNLEADED 5 JETFUEL 2 WASTE 2 LEAOEO e 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF(A.T)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.t III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A B.ANDC.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ l SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO- D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING a 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION O 91 NONE O 95 UNKNOWN ❑ W OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I 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 A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 0 CONCRETE A U 7 STEEL WI 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 DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 W IML 99 OTHER MONRORNG ❑ V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING 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 IPMNTEO A 319NARIREI DATE -2 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW W STATE LD.* EO COUNTY 9 JURISDICTION 5 FACILITY X TANK A :IBJ Z PERMIT NUMBER J PERMITAPPROVED BYIDATE PER IT EXPIRATION DATES FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �� FOROQw6l0.^/1