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6°°4 f ♦� C STATE OF CALIFORNIA ' s STATE WATER RESOURCES CONTROL BOARD + ° UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B .�� 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 F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE t;�'9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.9 OZ B. MANUFACTURED BY: K C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: r �� II.TANKC ENTS IFA-11S MARKED,COMPLETE ITEM C. A. en t MOTOR VEHICLE FUEL ❑ 4 OIL C. 1a REGUL R 8 3 DIESEL ❑ 9 AVIATION GAS EL ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ❑ IO PREMIUM 4 GASNpL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THATAPPLIES IN BOX A. TYPE OF ❑ 1 UBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM 2 S E WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ET�l BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100X METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ t RUBBER LINEDD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING S UNLINED ❑ 95 UNKNOWN ❑ 90 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP D_k6ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION Zf 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION SINGLE WALL rU 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL W100ATING A U 9 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL AV 0 CATHODIC PROTECTION A U 95 UNKNOWN A U 90 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK MIMOTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31 MONRORINO ❑ 99 OTHER V.TANK LEAK DETECTION ❑ t AL CHECK INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LASTUSED( V iil 2.ESTIMATED GUANTITY OF 3.WAS TANK FILLED WITH p/ 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 DATE IPWNTE9 S SIGNATUFEI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION 9 FACIL IF TANK# STATE I.D.# p O o D A4t-'?s PERMIT NUMBER PERMIT APPROVED BYA3ATE PERMIT EXPIRATION DATE F.Il; FORM B (9901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 1 {7 4 FOROOI6B/M✓—/)