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�- STATE OF CAUFORNA STATE WATER RESOURCES CONTROL BOARD - t� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EA ANK SYSTEM. • °a.-oy; MARK ONLY 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 3 CHANCE OF INFORMATION ❑ 7 PERMANENTSII- , ONE(TEM ` 2 INTERIM PERMIT ❑ K AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE Q 8 TANK REMOY4D O/ OBA OR FACILITY NAME WHERE TANK IS INSTALLED: �j y 9 i/� �� 7 6, �p � I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A OWNER'S TANK LD.8 S. MANUFACTURED BY: C. DATE INSTALLED(MO/OAY)YEAR) /2 7M TANK CAPACITY IN GALLONS: aa-Zl II.TANKC ENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ s OIL B. C. ❑ 1a REGULAR G DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT O IOPREMIUM A GASAHOL ❑ UNLEADED 5 JETFUEL 7 METHANOL ❑ T CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE a 2 1EAOED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.t: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN B01 A. TYPE OF ❑ DOUBLE WALL El0 SINGLE WALL WITH EXTERIOR LINER ❑ S5 UNKNOWN SYSTEM V SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ N OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 0 F18ERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑I 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 1001 METHANOL COMPATIBLE W/FRP (Pnmmy Tank) ❑ 9 BRONZE II 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 KYO LINING ❑ S EPDXY LINING ❑ A PHENOLIC LINING - C.INTNNIGR F-15 GLASS LINING lo's UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER V IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP �COATING ❑ S VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTIONVF 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEGMOOR U IF UNDERGROUND,BOTH IF APPLICABLE U A. SYSTEM TYPE A U 1 SUCTKON A 2 PRESSURE A U S GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U G LINED TRENCH A 95 UNKNOWN A U W OTHER C. MATERIAL AND A U I SAFE STEEL A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AV 25 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LWETGHTNESS TESTING ❑ 5KTIiRSTTAL W OTHER MONffOANG ❑ V.TANK LEAK DETECTION ECK 2 RY RECONCILIATION 3 TTESTING 7 INTERSTITIAL MONITORING 91 06 VISUAL ANK HTING ❑ TI ❑ VAPOR NONE MONITORING O AUTOMATIC 99 OTHER TANK GAUGING Q WATER MONITORING 8 VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED OUANTITY OF 3.WASTANKFILLEDWI7H YES ❑ NO❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICMITS NAME DATE (PPoMTEO a SIGNATIlFC1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTICN x FACILITY 9 TANK 9 STATE I. k 0 �� aM � O 0 PERMIT NUMBER PERMIT APP VIED BY PERMIT EXPIRATION DATE FORM B (a9q TWS FORM MIDST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.