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CSTATE OF CALIFORMA STATE WATER RESOURCES CONTROL BOARD .o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. o'lnonn`' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6 Q I's I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK L D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) 6 D. TANK CAPACITY IN GALLONS: ;00 II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL OIL B. C. ❑ la REGULAR DED 8 3 DIESEL g AVIATIONGAS ❑ 2 PETROLEUM a 80 FAIPTV ❑ 1 PRODUCT ❑ 1b PREMIUM ` GASAHOL ❑ UNLEADED S JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 1E ❑ 2 LEADEDOTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED �1 / �� i y ' C.A.S.9: III. TANK CONSTRUCTION MARKONE ITEMONLY IN BOXES A.BLANCO.ANDALL T14ATAPPLIES IN BOX 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 1 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 (Pdmuy TmY) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 IILXYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING UNING ❑ 5 GLASS LINING ❑ 6 UNLINED O'7S UNKNOWN ❑ 99 OTHER 19 LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION O 5 CATHODIC PROTECTION ❑ 91 NONE OWN ❑ 99 OTHER 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 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 6ysw.LE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 90 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLWINYL CHLORIDE(PVgp U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL YIN COATING A U 8 100% METHANOL COMPATIBLE W/FRp PROTECTION A U 9 GALVANVED STEEL A U 10 CATHODIC PROTECTIONA UNKNOWN A U 99 OTHER D. LEAK DETECTION E:] �I AUTOMATIC LINE LEAK DETECTOR KINE TIGHTNESS TESTING3 L ❑ MWONRORNG Q OTHER V.TANK LEAK DETECTION ❑ 1VISUAL CHECK TESTING [:] 2 INTERTOO1RY MRpR GRECONCILIATION ❑ VE MONITORING[:] 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 31 NON ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(M01DAY/Y111) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I 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 IIN9NTgD A$MNATIIREI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE 01COUNTY# JURISDICTION# FACILITY#2;019j TANK* j"c /-/ /3 J PERMIT NUMBER .�/ PERMIT APPROVED—BYLIDATE 6 PERMIT EXPIRATION DATE tf FORM B (9-9) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. i ! I FORU911B-RI I