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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3y. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "mom ya COMPLETE A SEPARATE FORM FOR EA PH TANK SYSTEM CJI MARK ONLY NEW PERMIT L] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL CLO SITE ,/-y ONE ITEM ' ❑ INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Q S TANK REMO ED / l(vJ (' DBA OR FAC AME WHERE TANK IS INSTALLED: G QJ Jl70 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A.OWNERS TANK I.D.xB. MANUFACTURED BY: zt K-T NS C. DATE INSTALLED(MOCAY/YEAR) I dolD. TANK CAPACITY IN GALLONS: 11.TANK C ENTS IFA-11SMARKED.COMPLETE ITEM C. A t MOTOR VEHICLE FUEL ❑ a OIL B. C. aUNLEADED R 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRDDl1CT ❑ 10 PREMIUM 6 GASAUEL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED CAS •: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX A TYPE OF ❑ 1 BLE WALL F73 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SI LE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑�D LINING ❑ 3 EPDXY LINING ❑ l PHENOLIC L.INI/NG C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 96 UNKNOWN ❑ 9D OTHER V/� LINING S LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 32,QtrATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEO NOOR U IFUNDERGROUND.BOTH IF APPLICABLE A. SYSTEMTYPE A U 1 SUCTION A U 2 PRESSURE A U 7 GRAVITY A 90 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U s FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 W/COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TNKMG ❑ T NTERnTIALMONORWG ❑W OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ W OTHER /r VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ ❑ SUBSTANCE REMAINING GALLONS INERTMATERNL? NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE; IS TRUE AND CORRECT APPLICANTS NAME DATE IPPoNTE9a91GHATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY s ' TANK x OD STATE ri,lDoa,r--o L D PERMIT NUMBER PER i APPRQ)(ED BY T PERMIT EXPIRATION DATE FORM B (9 901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FIXi0mC6M