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^�b� N P9 STATE OF CALIFORNIA _ ��`" STATE WATER RESOURCES CONTROL BOARD + '' W��, a o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >A o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT F73 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBAOR FACILITYNAME WHERE TANK IS INSTALLED: V =El I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFYIFUNKNOWN A. OWNER'S TANK I.D.# el?. B. MANUFACTURED BY: I9 C. DATE INSTALLED(MO/DAY/YEAR) kl D. TANK CAPACITY IN GALLONS:/ DV. ILTANKCONTENTS FA-11SMARKED,COMPLETE ITEM C. A � I—MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ tAUNLEADED REGULAR 3 DIESEL 6 AVIATIONGAS 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY ��PRODUCT ❑ 1 UNLEADUlmED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER Ewl1�5 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑m/7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP F(PdmuyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL '" UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED E::] 2 ALKYD LINING 3 EPDXY LINING F14 PHENOLIC LINING C.INTERIOR F-15 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN E] 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING O VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E::] 5 CATHODIC PROTECTION F-191 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,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 :)5 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 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONOORIIANO ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER 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 3.WAS TANK FILLED WITH 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 (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# - TANK# STATE I.D.# m 6 PERMITNUMBER PER MIT APPROVED BY/DATE MIT EXPIRATION DATE / FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. //////�� FORO¢MB#i/ /