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• • L�OV STATE OF CALIFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B e 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT6 CHANOE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a TANK REMOVED TEL DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.11U, K, B. MANUFACTURED BY: //. �/ C. DATE INSTALLED(MO/DAY/YEAR) i./, K 0. TANK CAPACITY IN GALLONS: II.TANKCO ENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHK;LE FUEL ❑ 4 OIL B. 0. ❑ t UREGULARNLEADED 3 DIESEL ❑ S AVIATION OAS _ ❑ 2 PETROLEUM ❑ 90 EMPTY �RObl1CT 18 PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 6 JET FUEL F-13 CHEMICAL PRODUCT E:] 95 UNKNOWN ❑ 2 WASTE O 2 LEADED ® 66 OTHER (bESCR19E IN ITEM D.BELOW) D. IF(A.1)19 NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.SA: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,9,ANDC,ANDALLTHATAPPUES INBOXD A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER [:�95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER S. TANK ❑ I RARE STEEL ❑ 2 STAINLESS BTEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAO Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 6 CONCRETE ❑ S POLYVINYL CHLORIDE ❑� T ALUMINUM ❑ S 100% METHANOL CDMPATIBLE W/FRP (PrIm4ryTonk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL LJ UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING-- ❑ 5 EPDXY LINING ❑ 4 PHENOLIC LINING :C.INTERIOR ❑ 6 GLASS LINING ❑ B UNLINED 2-6 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? Yrs_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE - - UNKNOWN O 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNMAaAOUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 00 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 5 UNKNOWN A U OB OTHER C. MATERIAL AND A U I 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 1 StEELW/COATING A U B 10W. METHANOL DOMPATIBLEWffRP PROTECTION A U 9 GALVANFLED STEEL A U 10 CATHODIC PROTECTION A�B/05 UNKNOWN A U 02 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑09 OTHER V,TANK LEAK DETECTION �❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGINd❑ 6 GROUNDWATER MONITORING ❑ 6 TANK tESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ 09 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNA) 2.ESTIMATED OUANTITY OF &WAS TANKFILLEDWITH SUBSTANCE REMAINING GALLONS INERT MATERIAL7 YES ❑ NO� THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 91DNATDREI LOCAL AGENCY USE ONLY THE STATE 1.0,NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILNY# TANK# STATE I.D,# PERMITNUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE J FORM B (9-9o) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR9DMR-R4