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y UR P E STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B e / COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSED ON S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ori /L I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: a W C. DATE INSTALLED(MOIDAY/YEAR) T Air SM D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGUL R DIESEL ❑ 6 AVIATKON GAS ❑ 2 PETROLEUM ❑ 00 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 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.i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE Of D?ll DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK La ' BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PNmaryTok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 GLASS LINING ® UNLINED ❑ 96 U�NfNOWN ❑ 98 OTHER LINING Zl IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP Prl FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑96 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATIO CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 CHLORIDE(PVC) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 1D0% METHANOL OOMPATIBLEW/FRP PROTECTION A U 9 GALVANIZEDSTEEL A U 10 CATHODIC PROTECTON A U 96 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONRORI GL ❑ 99 OTHER V.TANK LEAK DETECTION ❑ / VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING &r7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DAT S D(MO/DAY/YR) 2.ESTIMATED GUANTITY OF 3.WAS TANK FILLED WITH YES NO SUB STANCEREMAINING GALLONS INERTMATERIAL7 ❑ [L] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME ///LLL///jjj /J DATE IPR NTED a MNRTURE)//// ' T _V/ LOCAL AGENCY USE ONLY THE STATE I.D.N BER IS COMPOSED 0 T FOUR tolMBERS BELOW ` 11(§\ I - COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D. 6101 -401140:1 IV 0 PERMIT NUMBER I PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FMOa &R/