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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 34 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ ❑ 7 PERMANENTLY CLOSED ONSITE ❑ 6 TEMPORARY TANK CLOSURE [:] B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: oee(p Wv I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# /w B. MANUFACTURED BY: C. DATE INSTALLED(MO(DAY/YEAR(R) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.rOMPLETEITEMC. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL g, ❑ to REGULAR ❑ 2 PETROLEUM C. UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 80 EMPTY 1 PROIXICT ❑ 1bPREMIUM 4 UNLEADED 5 J ESE ❑SAHOL ] METHANOL ❑ 3 CHEMIGALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED H 99 OTHER (DESCRIBE IN IT D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF BUBSTANCE STORED vh G L D.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 13OXES A.B.AND C,AND ALLTHAT APPLIES INBOXDpNDE A. TYPE OF r-1i DOUBLE WALL E] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WA=RP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ C.IN1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 8 UNLINED �95 UNKNOWN ❑ 99 OTHER L4 LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION E::] 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE Affl 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL J U /0 CATHODIC PROTECTION 95 UNKNOWN A u 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 399 OTHER MONRORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IPRINTEG a SIGNA, , DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION GATE .ir, �/1 /7 FORM B p 91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,U LESS/"ryOURRENT FORMA HAS BEEN FILED. IIe�fj � FOii9m16-RS