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STATE OF CALIFORNIA ',f" t•. c WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ' COMPLET E A SEPARATE FORM FOR EACH TANK SYSTE?ti MARK ONLY ❑ 1 NEW PERMIT ❑ ] RENEWAL PERMIT ❑ 5 CHANGE CF INFORMATION ❑ 7 P£AMANENTLY CLOSED ON SIT,— ONE ITEONE ITEM ❑ 2 'N,GRIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED 08A OR FACGLTY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLE E ALL ITEMs- SPEC;FY IF UNKNOWN A. OWNER'S TANK 1.0.i I 3. MANUFACTURED BY: v I i C. OATS INSTALLED(MCIOAYNEAR) !� I 0. TANK CAPACITY IN GALLONS: Ii.TANK CONTENTS :FA.IISMAAKEO.CCMPLETETEMC. A. ❑ t MOTOR VEHICLE FUEL ❑ a OIL B, O to REGULAR �,''''�I� ] DIESEL ❑ g AVIATION GAS " UNLEACEO U a GASAHOL ❑ 2 PETROLEUM ❑ 60 EMPTY ❑ 1 PRODUCT ❑ lbPREUNLMI M ET FUEL METHANOL LJ S : ❑ 7A ❑ ] CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 `HASTE ❑ 2 LEAOEO ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(A.I)IS NOT.MARK20. ENTER NAME OF SUBSTANCE STORED C.A.S.S III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.3.ANO C.AND ALL`HAT APPLES IN BOX 0 A. TYPE OF ❑ 1 DCUBLE WALL ❑ ] SINGLE 'NALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE 'NALL ❑ a SECCNOAAY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ S. TANK1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ ] FIBEAGLASS ❑ a STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 PCLYVINYL CHILORICE ❑ 7 ALUMINUM ❑ 6 10(. METHANOL COMPATIBLE W/FRP (primary Tank) ❑ 9 BRONZE ❑ 10 GALVANREO STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ t RUBBER LINED ❑ 2 ALKYD LNWG ❑ ] EPDXY LINING ❑ A PHENCLX: LINING C. 'UNWGR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL CCAIPAT18LE WITH IOC% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTICN ❑ 5 CATHCCIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABCVEGROUND OR U !FUNCEAGAOUNO.30THIFAPPLCABL£ A. SYSTEM TYPE A U I SUC71CN A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONST RUC T ION 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 ] POLYVINYL CHLORICE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWI COATING A U 8 100% METHANOL C..MPAT18LE'NIFRP PROTECTION A U 9 GALVANIZ,.O STEEL A U 10 CATHCOICPROTECTICN A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTCMAT:C LINE LEAK CE ECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 "N cn 'I IAL MCNITCRING 99 OTHER C:] V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK F72 INVENTORY RECONCILIATICN El ] VAPOR MCNTCRING❑ A AUTOMATIC TANK GAUGING ❑ 5 GRCUND WA,ER,MCNITCRING ❑ , TANK TESTING ❑ 7 INTERSTITIALMONTORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION t, ES TWA EO GATE LAST USED(MO OAY/YA) I 2. SUBSTANCE REMAINING GAESTIMA ED CUANTITY OF ].WAS TANX F LLED WITH YES ❑ NO ❑ LLONS INERT.MA,eRIAL? THIS ECRM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PUNTED i SIGNATURfl LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ' STATE I.D. COUNTY$ JURISOICTICN x FACILITY S TANK S tt �/�r{�Z�❑ �❑ :J l 1 7� "' �I v PEAr,IIT\UMBER PERMIT APPROVED 3YIOATE PERMIT EXPIRATION DATE FC AM 3 (9-9OI THIS FORM MUST BE ACCOMPANIED BY A PERMS APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FCRo¢M 6.as dWJ