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STATE OF CALIFORNIA •... °i, *1010' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑/15 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY TANK CLOSURE ❑ S TANK REMOVED `. DBA OR FACILITY NAME WHERE TANK IS INSTALLED: q2 0 S. GGv I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.6 Q ' 8. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) l �'(�' D. TANK CAPACITY IN GALLONS: II.TAN NTENTS IFA-11S MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL B. C. to REGULAR 8 3 DIESEL S AV A ❑ UNLEADED ❑ MTKXN GAS ❑ 2 PETROLEUM El 90 EMPTY dl PRODUCT Q 10 PREMIUM 4 GASOHOL ❑ 7 METHANOL ❑ ❑ % ❑ ❑ UNLEADED ® Y ,OTHERL(DESCRIBE IN ITEM D. BELOW) 3 CHEMICALPRODUCT UNKNOWN 2 WASTE 2 LEADED 9 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX A TR TYPE OF (J II DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ % UNKNOWN SYSTEM LJ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAO W/FIBERGLASS REINFORCED PLASTIC B. TANK 9 POLYVINYL CHLORIDE 7 ALUMINUM B 100% METHANOL COMPATISLE W/FRP MATERIAL ❑ 5 CONCRETE ❑ ❑ ❑ (PrimmyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ % UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑ 'V D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F75 GLASS LINING S UNLINED ❑ % UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH I0 METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 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 kU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AD SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U % UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Ao JOS UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK OETEVIR ❑ 2 LINE TIGHTNESS TESTING ❑ T WERSTIN(i ❑99 OTHER wNrro 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 ❑ % UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDWANTITYOF 3.WAS TANK FILLED WITH ,E 1:1NO� SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE IPWNTE985NYMlUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBERS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY a JURISDICTION a FACILITY a TANK a GLOQL `T STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE C'7_ tlel z �ocM a I9-w) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. C- Foaomaa94