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STATE OF CAUFORMA �• b G STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B YI COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED (7 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I 15� . 14 co� I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a O B. MANUFACTURED BY: v lic C. DATE INSTALLED(MOIDAY/YEAR) L) IC D. TANK CAPACITY IN GALLONS: II.TANKC NTS IFA-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ 1aUNLEAOED DIESEL ❑ 6 AVIATgN GAS ❑ 2 PETROLEUM O EMPTY 1 PRODUCT ❑ 1D PREMIUM 4 GASANOL ❑ 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 NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 USLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM LE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.IN LINING 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER LINING ❑ ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ ING F79 VINYL WRAP ❑ 4 FIBERGLASS REMIFORCEQ PLASTIC `— PROTECTION ❑ 6 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVE GROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCT A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U LE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A UBARE STE 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 1W% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANDFD STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U W OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3MON7oRING [D 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USE (MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUB STAN CE REMAINING GALLONS INERTMATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (GRIMED a 3KiMATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �FACILFFY# TANK or OUTLE( STATE I.D.# � � 1 LJ� Q l PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DA I( FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY&PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN Fllfjq l!✓/% FammasRs bra i v��