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STATEOFCALIFORNA ^`��•• ^�� .� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ry, . COMPLETE A SEPARATE FORM FOR PeH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S� F ,C fP� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK L0.a B. MANUFACTURED BY: C. DATE INSTALLED(MOMAYNEAR) L4EEE E D. TANK CAPACITY IN GALLONS: If.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEMC. ,L ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL S, C ❑ tAUNUFJ170 3 DIESEL ❑ 8 AVIATION OAg ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ib PREMIUM 4 GASAHOL 7 METHANOL O 2UNEDED 5 .NET FUEL ❑ ❑j 7 CHEMICAL PRODUCT ❑ % UNKNOWN ❑ 2 WASTE 99 OTHER (DESCRIBE IN ITEM D.BELO" D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.S.ANOC.ANDALLTHATAPPLIES INBOXD A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ % UNKNOWN SYSTEM V2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER B. TANK Eg/l BANE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIOE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNNO ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING8 UNLINED LINING ❑ ❑ % UNKNOWN ❑ 9D OTHER IS LINING MATERIAL COMPATIBLE 'ATH 100%MET14ANOL 7 YES— NO— D.CORROSION ❑ 1 ;POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 90 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGPOUNDOR U IF UNDERGROUND,BOTH IFAPPLICASLE A. SYSTEM TYPE A1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A(U)9S UNKNOWN A-UN 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 e CONCRETE A U 7 STEEL YIN COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A19' U % UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 UNETIGHTNESSTE NO ❑ O NTE'ITOR GL ❑ W OTHER V.TANK LEAK DETECTION kr❑ 1 VISUAL CHECK ® 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ S GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNW40WN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DA TE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 1 WAS INERT MATERIAL?TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANPS NAME (MNTED A SKNAMU ATE LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ' COUNTY 8 JURISDICTION* FACILITY 8 TANK 8 STATE LDAFW7 E= o o D10110 / PERMIT NUMBER � PERMIT APPROVED BYIpATE PERMIT EXPIRATION DATE FORM B (9-901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.- FOAM8-M