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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B • ry: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTL CLOSE ON ONE ITEM ❑ 2 INTERIM PERMIT O a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE B TANK REMOVII,O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z (j�J, �N W w I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.t 8. MANUFACTURED BY: L. GATE INSTALLED(MO/DAYIYEAR) D. TANK CA'ACfTY IN GALLONS: ILTANKCONTENTS IFA-I ISMARKED.COMP TE ITEM C. J A. ❑ 1 MOTOR VEHICLE FUEL s OIL g, C ❑ la REGULAR 3 DIESEL ❑ e AVIATICNGAS ❑ 2 PETROLEUM a p EMPTY ❑ 1 PPRpDUCT ❑ 1D PgEMNM 8 a GASOHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 ! WASTE UNLEADED S FUEL ❑ 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(0.I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED W O C.0.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS A STEELCLAD 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 ❑ 9g OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E:] a PHENOLIC LINING C INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 96 UNIPJOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION a 5 CATHODIC PROTECTION O 91 NONE ❑ 93 UNKNOWN ❑ 0 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNOERGROUND.BOTHIFAPPUCABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I 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 I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ ]IN ML 99 OTHER MONRORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 WMASTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IPWNTED a 3W'HANHEI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE 1.04COUNTY x JURISDICTION N FACILITY x TANK x 9Z a / 0 PERMIT NUMBER ' �- PERMIT APPROVED BY/O�ATE PERMIT EXPIRATION DATE e) I FORM B 1&901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. �0800LbR1 4 (