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A t° STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD i m'tb � UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 4 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED — �]- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK L0.8l� ` B. MANUFACTURED BY:u C. DATE INSTALLED(MOA7AYNEAR) Ll�if WN D. TANK CAPACITY N GALLONS: ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. EllaREGULAR 8 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ N EMPTY ®, I PRODUCT ❑ Ib PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ® 2 LEADED N OTHER (DESCRIBE N REM D. BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXESAB,ANDC,ANDALLTHATAPPLIES INBOXD A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 96 UNKNOWN SYSTEM I®II 2 SMILE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Lm 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 107% METHANOL COMPATNLE W/FRP (PFImxyTWI) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED 2 AIKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 0 UNLINED 06 UNKNOWN O 99 OTHER LINING 10 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 F03ERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTKN ❑ 91 NONE 150 95 UNKNOWN ❑ N OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A U 1 SUCTION A if 2 PRESSURE A U 3 GRAVITY A U N OTHER B. CONSTRUCTION A®1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH UNKNOWN A U N 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 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A6?95 UNKNOWN A U N OTHER D. LEAK DETECTION 0 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 5rERSTITLAL ❑ MONITORING99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING C2 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) ji 2.ESTlMAATEDQUANTITYOF NCE REMAINING !-I A 3.WAS TANK FILLED WITH GALLONS INERTMATERIAL7 �ANYES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE - -9 1PRINTE0661GNATUREI L>✓a s Pr�irx• 7 LOCAL AGENCY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 0 JURISDICTION 0 FACILITY 0 TANK 0 STATE LDA D Z I I I 1 1104 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (9 W) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORGIWSN