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d�ll STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD '�'c•o �; UNDERGROUND STORAGE TANK PERMIT APPLICATION. FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `'��•_�•' MARK ONLY ❑ 1 NEW PERMIT3 RENEWAL PERMIT ❑ 7 PERMANENTLY CLOSED TE ❑ ❑ S CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED j OBA OR FACILITY NAME WHERE TANK IS INSTALLED: v 4 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.i B, MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) (� D. TANK CAPACITY IN GALLONS: O V II.TANK CONTENTS IFA-11SMARKED.COMPLETE ITEM C. q, OTOR VEHICLE FUEL OIL B. C ❑ 1aUNLEADEO 3 DIESELFir a AVIATION GAS O 2 PETROLEUM ❑ 80 EMPTY �RODIICT �T6PREMIUM • GASAHCL ❑ 7 METHANOL ❑ 3 CHEMK:ALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED �n'�q S JET FUEL ❑ [2 LEADED L__I W OTHER (DESCPIBE IN REM D,BELOW) D. IF(A.1)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THATAPPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINEfl 95 UNKNOWN SYSTEM ❑SINGLE WALL 0 SECONDARY CONTAINMENT (VAULTEOTANIQ ❑ 9a OTHER B. TANK ❑ 1 SARESTEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Plmiry Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL N ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C R ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING I LINING ❑ 5 GLASS LINING ❑ 8 UNLINED 96 UNKNOWN ❑ 9D OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ l FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE95 UNKNOWN O 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 6PJ PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 oouatE WALLA U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE CORROSION A U 5 ALUMINUM A U 8 CONCRETE (pVC)A U A FIBERGLASS PIPE A U 7 STEEL WlCOATING A U S 100% METHANOL COMPATIBLE W/Fpp PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PgOTECTgN p� UNIOJOWN p U 90 OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR LINE TKiHTNESS TESTING 7 ❑ MOIROgING ❑ OTHER INTER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECKINVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING E:] 95 UNKNOWN 91 NONE ❑ ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAIOyR) I ? ESTIMATED OUANTITY OF 1 WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING E:3NS INERT MATERIAL? YES ED NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTS NAME IPmNTE9 a slcruTUl>E1 DATE LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW C® JURIS�Ci FACILITY TANK I STATE I.D.# �T�J 1-3 } PERMIT NUMBER Qj�PEHMITAPPROVED BY/DATE� / PERMR EXPIRATION DATE ) FORMS (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Il• I FORamt6f%