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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD •e• /�" e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o^ ems/ y a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ' Cil/so•M�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM O 2 INTERIM PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE e TANK REMOVED o9 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: loin n ., n.. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN k� A. OWNERS TANK I.D.# A. TYPE OF WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER B. MANUFACTURED BY: SYSTEM C. DATE INSTALLED (MQOAY/YEAR) ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK D. TANK CAPACITY IN GALLONS: �O II. TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. MATERIAL ❑ 5 CONCRETE A. 1 MOTOR VEHICLE FUEL ❑ I 011 B. C O IRREGULAR 3 DIESEL ❑ 2 PETROLEUM ❑ BO EMPTY�/ UNLEAAD PRODUCT O ib PREMUM 4 GASAHOL ❑ e AVIATION GAS ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE UNLEADED 2 L ❑ EADED ❑ 5 JET FUEL ❑ 7 METHANOL D. IF C INTERIOR ❑ 99 OTHER (DESCRIBE IN ITEM O. BELOW (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 99 OTHER PROTECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES _ NO— 9 GALVANIZED STEEL C.A 3.#: III. TANK CONSTRUCTION .AR ,......__. ❑ 2 COATING E 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC IV. PIPING INFORMATION CIRCLE A IFAROVEGROUNDOR U IFIINOFRAROIINO RGTNIR eRR1 II c A. ❑ 1 DOUBLE _.._...-.,,,,,",,,, p, nnv.,. wv� ALL I NAI APPLIES IN BOX D A. TYPE OF WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN SYSTEM ❑ 2 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 ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PdmayTmlk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER CORROSION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER PROTECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES _ NO— 9 GALVANIZED STEEL D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 DUNE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAROVEGROUNDOR U IFIINOFRAROIINO RGTNIR eRR1 II c A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 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 STEELMODATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31 STITIAL❑ 99 OTHER MONITORING V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 9 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER TANK FILLED I1. ESTIMATED DATE LAST USED (MO/DAV/YR) I2 SUBSTANCE REMASTIMATED QUANTIINING TY GALLONS 13WA INERTMATERIAL9H YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND COR APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) ECT LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# lallI I 11 6 2 O I segAsA? PERMITNUMBER I PERMIT APPROVED BY/DATE LRERUaZXPMAUQWCAiE L._I_ _ FORM B (9 90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED `.e