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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT c• ONE ITEM ❑ 2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE 4 AMENDED PERMIT g TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED t7 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3-1;7 o rf I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.% !/ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS:` 0 — 11."TANK NTENTS FA-71SMARKED,COMPLETE ITEM C. A. MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR 3 DIESEL ❑ 2 PETROLEUM O 80 EMPTY UNLEADED ❑ 6 AVIA ION GAS 1 PRODUCT 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 4 1b LEADED ❑ 5 JET FUEL ❑ 7 MET gNOL D. IF(A-I)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED FL—J� LEADED ❑ 99 OTHER (DESCRIBE IN ITEM . BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B,ANDC,AND C.A.S.#: ALL THAT APPLIES IN BOX Dp E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL ❑ 4 5 UNKNOWN SECONDARY CONTAINMENT (VAULTED TANK) 98 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL --_ — ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ g POLYVINYL CHLORIDE -E� 7 (Primary Tank) lyySJ'f/ ALUMINUM ❑ g 100% METHANOL COMPATIBLE W/FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C.INTERIOR 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN D 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO— PROTECTION ❑ i POLYETHYLENE Wggp ❑ 2 COATING PROTECTION ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLEC(NEAR) IV.PIPING INFORMATION CIRC=lU E A IFABOVE GROUND OR U IF UNDERGROUND.BOTH EF APPLICABLE NTION EQUIPMENT INSTALLED YEAR) PE A UCTION p U 2 PRESSURE TION A U 1 A U 3 GRpVITV A U 99 OTHER SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCHAND A U 1 BARE STEEL p UNKNOWN p U gg OTHER N A U S ALUMINUM A U 2 STAINLESS STEEL A U 3 WIL CHLORIOE(PVC)A U 4 FIBERGLASS PIPEON A U 6 CONCRETE A U 7 STEELW/COATINGA U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 9 100% METHANOL COMPATIBLE /FRP CTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR UNKNOWN A U 98 OTHER 2 LINE TIGHTNESS TESTING � 3 V.TANK LEAK DETECTION MONRORING ❑99 OTHER ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING UTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONIT RING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 97 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/VR) 2.ESTIMATED CUANTITY OF SUBSTANCE REMAINING GALLONS 3 WA INERTMATERIALTANK FILLEDI7H YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FA I.D.# �—m � TANK# EPERMITNUM87ER ERMI7 APPROVED BY/DATE PERMIT E%PIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.-7-- 9 • 0 //P,/ F0R99J2 q5