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STATE OF CALIFORNIA s e� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ry; COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY O D ITE ONE REM ❑ INTERIM PERMIT ❑ l AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 11FI, s7wlp- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# 11, B. MANUFACTURED BY: G C. DATE INSTALLED(MOIDAYWEM) D. TANK CAPACITY IN GALLONS: II.TANK WENTS IFA-1 ISMARKED,COMPLETEITEMC. ❑ ❑ la REGUNLEULAR 3 DIESEL ❑ 8 AVIATION GAS A. 1 MOTOR VEHICLE FUEL 8 OIL 9, C. d GASAHOL ❑ 2 PETROLEUM ❑ BO EMPTY t PRODUCT ❑ 1bUNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPROWCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA.B.AND C.AND ALLTHATAPPLIES INBOX0 A. TYPE OF ❑ DOUBLE WALL F73 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 LE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ W OTHER 1 B. TANK BARE STEEL ❑ 2 STAINLESS STEEL E:] 3 FIBERGLASS ❑ d STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALV IZEO STEEL ❑ 95 UNKNOWN ❑ 20 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING C::] d PHENOLIC/LINING C.INTERIOR F-15 CLASS LINING UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER (/ /t•, LINING 64 LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP [:] G F] 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ CTX3N VolS CATHODIC PROTENONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEG ND OR U IF UNDERGROUND.80T1 IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 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 p 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 d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOIC PROTECTION A'r� 96 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 DITERSMAL MONITORING ❑99 OTHER V.TANK LEAK DETECTION SU W91 TOMATIC TANK TESTING ❑ 7 INTERSUAL CHECK [Er2 STITIAL MONITOINO RY IR ❑ VAPOR ANONEMONITORINGO 95 AUNKNOWN TANK GAUGING S�GORn01UEq WATER MONITORING VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOI)AYNM 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES [:] 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 DATE IOgrITEp i SIGNANRq LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 00 STATE LDAM O 0 D O PERMIT NUMBER II PERM I MPROY�Y AT PERMIT EXPIRATION DATE 1 FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ^f `/ FUM1M(Ot8 j5 �� i� I.YD