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STATE OF CALIFORNIA . `y STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �1�II COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONfil ONE ITEM ❑ 2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE � 8 TANK REMOVEDFO---q O- y DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D S r „y' C/ I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN J A. OWNER'S TANK 1.D.If / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYKEAR) LA<-f4aD. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGUL3 DIESEL ❑ 6 AVIATIONGAS EO ❑ 2 PN ❑ 80 EMPTY ❑ 1 PRODUCT 1b PREMIUM 4 GAS AHOL 7 METHANOL 3 CRODUCT ❑ UNLEADED 5 JET FUEL ❑ ❑ ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 0 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS ND, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUC ON MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX41NDE A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SI WALL ❑ 4 SECONDARY CONTAINMENT (VAULTS NK) ❑ 99 OTHER B. TANK ❑ 1 BARE E ❑ 2 STAINLESS STEEL ❑ 3 F GLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRE ❑ 6 POLYVINYL CHLORIDE ❑ 7 UMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INUNNIGR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE ITH 100%METHA 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED AR OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOViiZROUND OR U'IKPNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 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 BARE STEE A U 2 STAINLESS STEEL U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U5 ALUMINU A U 6 CONCRETE A 7 STEEL W/COATING A U 8 1009/ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALV IZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUT ATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TES ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTO TIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF S.WAS TANK FILLED WITH YES ❑ NO❑ 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 (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNS CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDE OU STORAGE TANK REGULATIONS FORMS (12-91) n I I _ ((% 1�j I FOR06]68.116