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• STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT U25 CHANGE OF INFORMATION ❑ ERMANE Y C SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK R ROVED , DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1217 7 IA/, Z-Z�� I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: OQQ II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ A OIL g- C ❑ to REGULAR 3 DIESEL UNLEADED ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 10 PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTEUNLEADED 5 JETFUEL ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOY+1 D. IF(AL1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.J III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER A. TYPE OF ❑ ❑ 95 UNKNOWN SYSTEM EIZ2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100. METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ tO GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNNG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING 8 UNLINED LINING ❑ ❑ UNKNOWN M 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_t POLYETHYLENE WRAP NO— D.CORROSION 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 9 KNOWN ❑ 99 OTHER IV.PIPING INFORMATIOIN CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A J I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A( 5 UNKNOWN A U 99 OTHER C. MATERIAL AND A U t 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 8 CONCRETE A U 7 STE L W/COATING A U 8 100. METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTK) A 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31N i UL G ❑ 99 OTHER MCNRORIN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 1� ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1,ESTIMATED GATE UST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE/ / (PRINTED a$IGNAIURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBER$ tA — q COUNTY# JURISDICTION# F I ITY# I TANK# /y STATE LD. FTTI O d o 6 DRl PERMIT NUMBS R PERMIT APPROVED BY/DATE .1T EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROOIaB-fU