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0 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 ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / V 11 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z(y p i-06 / A L/or-- ❑ 3 FIBERGLASS 6 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC I TANK(1PSCRIPTION cnMPI PTF ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# ❑ A OIL ❑ BO EMPTY ❑ 95 UNKNOWN • B. MANUFACTURED BY: 'Ic, 8 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL ❑ T METHANOL 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. DATE INSTALLED (MO/DAY/YEAR) 2 SINGLE WALL 0 D. TANK CAPACITY IN GALLONS: AIV2 DOUBLE WALL A U II TAAIvpnkffcNTC wov of cIc TPMl A 1 MOTOR VEHICLE FUEL ❑ 2 ETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ A OIL ❑ BO EMPTY ❑ 95 UNKNOWN B. I PRODUCT ❑ 2 WASTE C. 1aUNL U EI ❑ 1 PREMIUM UNLEADED ❑ 2 LEADED 8 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL ❑ T METHANOL 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED go&n 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER 111 TAMIL PAI,ICTGIIPTKIN n1JCI[UnUVINMnYC9A P ANnn ANn AIIITHATAPPIIFSINROXDANDE IV PIPINr INFORMATION CIRCI F A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM B. 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER AIV2 DOUBLE WALL A U F71 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 6 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE r77 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PNmaD/Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 8 100% METHANOL COMPATIBLE W/FRP ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING EPDXY LINING ❑ 6 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �3 95 UNKNOWN ❑ 99 OTHER LINING MOMRORING ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV PIPINr INFORMATION CIRCI F A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p GY2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AIV2 DOUBLE WALL A U 3 LINED TRENCH A U 96 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 AOTHER D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK QETECTOR ❑ 2 LINE TIGHTNESS TESTING MOMRORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING E�Y7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO C:]SUBSTANCE 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 (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # I TANK # UD STATE I.D.# = a PERMITNUMBEfl PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOROaMSM