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ne STATE OF CALIFORNIA `i STATE WATER RESOURCES CONTROL BOARD su o UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �`� Ye COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c�4ip""�� o MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 0 6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED /( DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 309, Ll I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.0 O `1_ _ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) u D. TgNK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O ❑ faUREGULARNLEADED 3 DIESEL 0 e AVIATION GAS ❑ 2 PETROLEUM 0 SD EMPTY 1 PRODUCT ib PREMIUM 4 CASAHOL 7 METHANOL 0 3 CHEMICALPROOUCT 0 95 UNKNOWN 0 2 WASTE 0 2 UNLEALEADEDED 0 5 JET FUEL E:] ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.III: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C.AND ALL THAT APPLIES IN SOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 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 (PHmaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 0 99 OTHER 0 1 RUBBER LINED 0 2 ALKYO LINING 0 3 EPDXY LINING 0 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN 0 99 OTHER LING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP 0 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION 91 NONE 095 UNKNOWN 0 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 U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A4)1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION Ali 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION INTIiNSPTAL 01 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING ❑ 0 MONID ING ❑ 99 OTHER V.TANK LEAK DETECTION 0 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITOR ING 6 TANK TESTING 7 INTERSTITIAL MONITORING 0 91 NONE 0 95 UNKNOWN 0 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM T D DATE LAST USED(MO/DAV/Ygi 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PAI T D8SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION Al FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U DERGROUND STORAGE TANK REGULATIONS FORM (f2-91) `f 6IQl95s�,+I��g FOBODM6R6