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STATE OF CALIFORNIA4P ✓" : TE')NATER RESOURCES CCNTROL BOARD "F �*` 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 C�GSED C SITE CNE ITEM Q 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED,/iI / 08A OR FACILffY NAME WHERE TANK IS INSTALLED: r(/ 2 v1^ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPEC:FY;F UNKNOWN y A. CWNEr1'S TANK 1.0.a 9. MANUFACTURED BY: C. 0A T E INSTALLED(MGOAY/YEAA) !`' I 0. TANK CAPACITY IN GALLONS:: II.TANK C EMS IFA•1ISLIARKED.CCMPLETEITEM C. q Cffl MOTOR VEHICLE FUEL ❑ a OIL 3, C. in 1a RE ULAA 3 DIESEL 8 AVIATION GAS UNLEADED ❑ ❑ 2 PETROLEUM ❑ 80 EMPTY ( 1 PRODUCT lbPREM RJM a GASAHOL 7 METHANOL UNLEADED 5 JET FUEL ❑ ] CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 `HASTE `❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(A.1)IS NOT.MARK20. ENTER NAME OF SUBSTANCE STORED C.A.S.1: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.3.AND C.AND ALL THAT APPLIES IN 9CX 0 A. TYPE OF ❑ 1 DOUBLE WALL (❑ 3 SINGLE 'NALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ a STEEL CLAD 'NI FIBERGLASS REiNFORC20 PLAS^C MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL C14LCRICE 7 ALUMINUM ❑ 8 100% .METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 3RONZE ❑ 10 GALVANCED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNWG ❑ 3 EPDXY LINING ❑ a PHENOLIC LINING C. UNING'Ti ER IC R ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 9g OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO_ D.CCRRCS(CN ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S CATHODIC PROTECTAN ❑ 91 NONE ❑ 95 UNKNCWN a 99 OTHER IV.PIPING INFORMATION CIRCLE A IFA3CVEGRCUNDOR U ;FUNCERGRCUND.30THIFAPP_ICA8LF A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY _ A U 99 OTHER B. C',NST RUCTION A U 1 SINGLE WALL A U 2 DCUSLE 'NALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICCATING A U 8 100% METHANOL CCMPATIBLE'NiFRP PROTECTION A U 9 GALVANZE0 STEEL. A U 10 CAT14COICPROTECTICN A U 95 UNIKNCWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE —,E LEAK CE CTOR C:] 2 LINE TIGHTNESS TESTING F-13 :N 1 uL MCNITCAING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECCNCILIATCN ❑ 3 VAPOR MCNITORING❑ t AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MCNITCRING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY(YR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT.MATERIAL? YES ❑ NO❑ THIS,-CRM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF,NY KNOWLEDGE, IS TRUE AND COPRECT APPLICANT'S NAME DATE POMTE0 a SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.O.,NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY$ JURISOICTICN x FACIL1 Y x TANK 0 STATEN:D.tt.� �� _ 1 1 1 1d PEf3MIT\UMBER I PERMIT APPROVED 3Y/DATE PERMIT EXPIRATION GATE FORM 3 (9-901 THIS FCRM MUST BE ACCOMPANIED BY A PERMIT APPUCATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. fORom+3:M