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STATE OF CALIFORNIA �� � c� STATE WATER RESOURCES CONTROL BOARD -•,+`� .? UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B :; ryr . COMPLETE A SEPARATE FORM FOR EA H TANK SYSTEM. �"'"""^'- MARK ONLY I NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ❑E ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: "/ST /� 53O 94 , I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A.OWNEf7S TANK I.D.tle B. MANUFACTURED BY: p �N G DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK NTENTS IFA-I ISMARKED.COMPLETE ITEM C. AR A. .� I MOTOR VEHICLE FUEL ❑ A OIL B. 0. ❑ IAONLEAOED S DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT IOPBEMIUM El A GASAHOL ❑ 7 METHANCL I❑ 0 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ UNLEADEEADED ❑ 5 JET FUEL ❑ W OTHER (DESCRIBE IN ITEM 0. SELOM D. IF(A.0 IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.l III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑�7']//_I DOUBLE WALL F70 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM u ' NGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANIq ❑ 99 OTHER B. TANK 1 SAFE STEEL ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS ❑ A STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Pnmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ;❑ 1 RUBBER LINED ❑�D LINING ❑ 2 EPDXY LINING ❑ A PHENOLC LINT C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE NTH 100% METHANOL? YES_ NO_ - O.CORROSION ❑ 1 POLYETHYLENE WRAP COATING ❑ S VWYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNOOR U IFUNDERGROUNO,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U (3)PRESSURE A U 9 GRAVITY A U W OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U i SAFE STEEL A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 ST VU COATING A U B 100X. METHANOL COMPATIBLEmFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECT)ON U S UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC—LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ ) INTERSTITIAL MONRORWG ❑99 OTHER V.TANK LEAK DETECTION / ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 0 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING C:] 5 GROUND WATER MONITORING }- SE1 8 TANK TESTING ❑ 7 INTERSTMALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION (.'ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES C::] NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT$NAME DATE I'..a SIGIIAN 0 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY k JURISDICTION 9 FACILITY x TANK* STATE I.D.# ® Q01 Dp PERMITNUMB R PERMIT AF? VED SflDAT Z (ti ( PERMIT EXPIRATION DATE FORM B (9-9M THIS FORM MIDST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. / FORomaaaA