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Mill . • ♦46ouuy C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ao , o° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATI '] ERMA ENTLY C ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMEND ORARY TANK CL RE a ANK EMOVED DBA OR FACILITY NAME WHERE TANK ALLIED: , L � /c.. I. TANK DESCRIPTION MP TE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C C. DATE INSTALLED(MO/DAY/Y AR) D. TANK CAPACITY IN GALLONS: ILTANKC ENTS A-1 IS MARKED,COMP ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ IS REGULAR ❑ 3 DIESEL ❑ AVIATION GAS EMIUM ❑ 4 GA AHOL ❑ 2 PETROLEUM ❑❑ 90 EMPTY PRODUCT ❑❑ 1bUNLEAO D ❑ JET FUEL 7 METHANOL ❑ 3 CHEMICAL PRODUC 95 UNKNOWN 2 WASTE 2 LEADED gg OTHER (DESCR IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER ME OF SUBSTANCE STORED �{ �L 0.A. III. TANK CONSTRUCTION MAR E ITEM ONLY IN BOXES A B.AND C,AND ALLTHAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 OWN SYSTEM SINGLE WALLONDARYCONTAINMENT 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EP XY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ED.Allf V3NYL ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E::] ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 6 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTER TITIA ❑99 OTHER �1* V.TANK LEAK DETECTION \1t!`-� ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AU IC TANK GAUGING E] 5 GROUND WATE NITORING ~\\ ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/VR) 2 SUTBAN STADCE REMAITY OF NING NG GALLONS 3 WAS TANK FILLED INERT MATERIAL 4H YES❑ NO ❑ ' THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR ,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTSNAME DATE r] 2 (PRINTED 4 SIGNATURE) '/ 7 LOCAL AGENCY USE ONLY HE STATE I.D.NUMBER IS COMPOSED OF THE F6QR NUMBERS BELOW COUNTY# JURISDICTION# M TY 6 # STATE I.D.# PERMITNUMBER PERMIT APPROVED BY/ r/1 _7 E%PIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. PA I 4b e . �R