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STATE OF CALIFORNIA J a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY+TANK CLOSURE ❑ 8 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 36,eq I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# L B. MANUFACTURED BY: /k- C. DATE INSTALLED(MO/DAY/YEAR) ds D. TANK CAPACITY IN GALLONS: 5ve? ILTANKCONTENTS IFA-11S MARKED,COMPLETE REM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL 8. C. ❑ IAUNELFADUED 3 DIESEL ❑ g AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ lb PREMIUM 4 GpSAH01 ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORSO C.AS.0 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK1 BARE STEEL F72 STAINLESS STEEL F-] 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING F-] 5 GLASS LINING ❑ 6 UNLINED g-g6-Uµ(NOWN ❑ 9B OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO— D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROIF APPLICABLE UND BOTH A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE GRAVITY A U W OTHER B. CONSTRUCTION A SINGLE WALL A U 2 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION p UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETEC"IR ❑ 2 LINE TIGHTNESS TESTING ❑ 91NIMONERSTI IAL 99 OTHER RORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING UTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING —7INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MpTERIAL7 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 StGNATI)REI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# M © 6 PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE Z FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMrF APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM&M