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STATE OF CALIFORNIA ,� STATE WATER RESOURCES CONTROL BOARD s 1° UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B .m� "� � , a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7.PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNERS TANK I.D. B. MANUFACTURED BY: C. DATE INSTALLED(MOYOAYNEM) 9, D. TANK CAPACITY IN GALLONS: Opp ILTANKCO S IFAAIS MARKED.COMPLETE REM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ IIIR GLEAD�EO 3 DIESEL ❑ 8 AVIATIONGAS A. ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 19 PREMIUM 4 QASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 88 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 BLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SBJOLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVAN STEEL ❑ 85 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2,AL160 LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING 8 UNLINED F-1KN 95 UNOWN ❑ 90 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ ATING F—] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION JVI 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 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL C14LORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUMa CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL 0 CATHODIC PROTECTION A U 95 UNKNOWN A U 90 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 NT STI ML ❑90 OTHER MONITORING V.TANK LEAK DETECTION F7>1 iSUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 2r 66 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST ED( AYiYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [-] NO a SUBSTANCE REMAINING GALLONS INERTMATERNL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE IPRINTE9 a 519N4TUPE1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# �—�--�TANK# m STATE I.D.# I i_J�L�LU�Q�pSy PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. //'/ F9INOMt