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STATE OF CALIFORNIA • ,ezoo"`< STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM. ie Cn�lfOn Mf MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E�rS CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED ONSITE ❑ 6 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /❑ B TANK REMOVED IF , I. TANK DESCRIPTION COMPLETE ALL ITEMS"- SPECIFY IF UNKNOWN / ��9 S� H . q. OWNER'S TANK I.D.# B. MANUFACTURED C. DATE INSTALLED(MD/DgyryEAq) p7 D. TANK CAPACITY IN GALLONS: ILTANKC ENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. [Zf is REGULAR ❑ 2 PETROLEUM O 80 EMPTY C. ❑ UNLEADED }� 3 DIESEL ❑ g AVIATION GAS 1 PRODUCT ❑ 1b PREMIUM u 4 GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WpBTE UNLEADED ❑ 5 JET FUEL ❑ T METHANOL [:D.:IF(A.1)IS NO MMARKED. ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 9g OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A S,ANDC,ANDALLTHATAPPLIES IN BO NDE S#. A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM El SINGLE WALL El UNKNOWN SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E]MATERIAL ❑ 5 CONCRETE 3 FIBERGLASS ❑ 6 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 6 POLYVINYL CHLORIDE ❑ 7 AL NUM (Primary lank) E] g BRONZE ❑ B 100% METHANOL COMPATIBLE W/FRp ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER ❑ ❑ 2 ALKYD LINING C,INTERIOR 1 RUBBER LINED ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? 95 UNKNOWN ❑ 99 OTHER VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION5 CATHODIC ❑ 3 VIN WgAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ PROTECTION ❑ 91 NONE ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) UNKNOWN 99 OTHER OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEMTYPE A U 1 SUCTION A U 2 PRESSURE B. CONSTRUCTION A U 1 SINGLE WALL A V 2 DOUBLE WALL A U 3 GRAVITY A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 3 LINED TRENCH p U 95 UNKNOWN A U 99 OTHER CORROSION A U 5 ALUMINUM A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE PROTECTIONA U 95 UNKNOWN p A U 6 CONCRETE A U 7 STEELW/COATING A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 9 100% METHANOL COMPATIBLEWIFRP D. LEAK DETECTION [:] 1 AUTOMATIC LINE LEAK DETECTOR U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING �V.TANK LEAK DETECTION MONITORING ❑99 OTHER_ ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/yR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING GALLONS INERT WAS TANK FILLED EART MATERIALI? YES NOH THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY APPLICANTS NAME KNOWLEDGE, IS TRUE A (PRINTED 8 SIGNAT REI ND❑CORRE❑CT DATE LOCAL AGENCY USE ONLY THE STATE I .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# STATE I.D.# Ta _ a yEyTog — PERMITNUMBERPERMITAPPROV� 49 17 � TE PERMIT EXPIRATION D TE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. �'J C� �/) 0 FOR064&R5