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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED ONSITE ❑ ❑ e TEMPoRAgy TANK CLOSURE O B TANK REMOVED DSA OR FACILITY NAME WHERE TANK IS INSTALLED: 20 oZ( , Saw I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# U r L-- B. MANUFACTURED BY: 12, /I C. DATE INSTALLED(MOIDAViYEAR) F D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IFA-11SMARKED.COMPLETEITEAIC. A . OTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ la REGULAR 3 DIESEL ❑ S AVIATION GAS ETROLEUM O BO EMPTY ❑ 1 PRODUCT 1bPREMIUM 4 GASAHOL- / UNLEADED 5 JET FUEL ❑ 7 METHANOLHEMICAL PRODUCT Y45 UNKNOWN O 2 WASTE 2 49D DTHER (DESCRIBE IN ITEM D. BELOW)OT MARKED, ENTER NAME OF SUBSTANCE STORED voCi40w,r,( D.A.B., III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.ANDC,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASSREINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ UMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (PrimwyTAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �NKNOWN ❑ 99 OTHER F-1 1 RUBBER LINED 2 ALKYD LINING C.INTERIOR ❑ EPDXY LINING ❑ 4 PHENOLICLINING LINING ❑ 5 GLASS LINING ❑ e UNLINED El95 UNKNOWN O W OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEL�j BS UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U W UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A 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 A(V95 UNKNOWN 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 B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AtgA UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ NT STRML sa MOI BORING OTHER &P V.TANK LEAK DETECTION F 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AU OMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITOR5 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO L-] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PLANTED A SIDNATUBE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TANK# STATE I.D.# ® = N PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE onr . Q FORM B(9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR98961M