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^LyOVq 0 +•� STATE OF CALIFORNA ./ �� STATE WATER RESOURCES CONTROL BOARD a m� , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMP E A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT a 4 AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE ❑ S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (o I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK LD.a S�ElocZ B. MANUFACTURED BY: n C. DATE NSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: �O II.TANK ENTS IFA•11SMARKED.COMPLETEREMC. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. aU EG ED 3 DIESEL ❑ a AVIATION GAS A. ❑ 2 PETROLEUM ❑ a0 EMPTY 1 PRODUCT Q Ib PREMIUM IIInI��- 4 GASAHOL ❑ 7 METHANOL 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ ❑ ❑ UNLEADED U 0JET L 0 2 U9 OTHER LEADED (DESCRIBE N ITEM D. BELOW) D. IF(At)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL Q 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER B. TANK F-11 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS STEEL CLAD iV/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE Q 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LIKED ❑ 2 ALKYD LINING ❑ OXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ W OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Q 5 CATHODIC PROTECTION O91 NONE 96 UNKNOWN ❑ 99 OTHER N.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 90 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LIKED TRENCH p U UNKIND A U 99 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/ A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANREO STEEL A U 10 CATHOOICPROTECTION A U UN IWOW A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORINGL Q 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4;ADTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ a TANK TESTING ❑ 7 INTERSTITIAL MONITORING Q 91 NONE 0,95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERNL7 VES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTE9 a 9KIN4TUNE7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# �--�TANK 0 m STATE I.D.#L/� ® 011,1q, PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B(990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORa9a1BIu