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STATE OF CAUFORNA 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 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT /I❑W.,,a TEMPORARY TANK CLOSURE ❑ a TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: If 3 3-75b IF •i- Yg I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.6O Z B. MANUFACTURED BY: L/ C. DATE INSTALLED(MOIDAYN kR) v, D. TANK CAPACITY N GALLONS: �� II.TANK C ENTS — IF A-11SMARKED,COMPLETEITEM C. A I MOTOR VEHICLE FUEL ❑ 4 OIL B• / C. ❑ 14UNLEADED a REGULAR 3 DL IESEL ❑ e AVIATXNJ GAS ❑ 2 PETROLEUM --I 60 EMPTY I�JT 1 PRODUCT LErlbUNL MEADEO 6 JET FUEL ❑ 7METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED W OTHER (DESCRIBE N REM D.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY N BOXESA.B.AND C.AND ALLTHATAPPLIES INBOXD ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 05 UNKNOWN A. TYPE OF 99 OTHER SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS MATERIAL ❑ [:j4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE F-16 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE WIFRP (PrimWTAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 MUSS LINING 6 UNLINED ❑ 96 UNKNOWN ❑ 90 OTHER LINING IB LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? VE8_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATI ED XVINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AM I STICTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTK)N AA o 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U Do OTHER C. MATERIAL AND A& 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 a 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 ❑1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTNG ❑ 5 MOE STrtIGL ❑ OTHER V.TANK LEAK DETECTION ❑ e TANK TESTING V INTERSTRLLLMRY ONROILIATION 3 RI ❑ 91VAPOR NONE 95 95 KNOWNOMATIC GAUGING Q❑ 0GOTHER WATER MONITORING VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 1PN,TED 4 S"ATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTV6 JURISDICTION x FACILITY III, TANK L�LJLJz STATE 04L1� PERMIT NUMBER RMIT APPROVED BYIDATE PERMIT EXPIRATION DATE L+r g/zz c( FORMS (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. �� PoROOH//6N