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STATE OF CALIFORNIA • �eeoPR e STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �� o COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5,/y I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN " A. OWNER'S TANK I.D.9 Q / l` B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CO NTS IFA-11SMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ laREGULAR ED DIESEL ❑ 2 PETROLEUM ❑ !b EMPTY 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JETFUEL ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCT N MARK ONE ITEM ONLY IN BO%ESA,O,AND C,ANO ALL THAT APPLIES IN BOX A. TYPE OF ❑ OUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 95 UNKNOWN GLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS SERGLASS TEEL ❑ 3 FIBERGLASS MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 UMINUM ❑ 6 100% METHANOL ICOMPA70ELW/FRP CED PLASTIC (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 OXY LINING C.INTERIOR ❑ 4 PHENOLK; LINING LINING ❑ 5 � LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_yyllyyN�� WRAP O_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 CRATING ❑ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE IILL�"77L3/ ❑ 4 FIBERGLASS REINFORCED PLASTIC 5 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A, SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p U 95 UNKNOWN p U 99 OTHER C. MATERIAL AND A V 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDEPVC CORROSION A U 5 ALUMINUM CHLORIDE(PVC) U 4 FIBERGLASS PIPE A U 1 CONCRETE U 7 STEEL COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 955 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR E:] 2 LINE TIGHTNESS TESTING ❑ 9 MONRORINGL ❑ � OTHE_ V.TANK LEAK DETECTION FEE�l VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOO//DAY/YR)_ 2.ESTIMATED OUANTITV OF l i; SUBSTANCE REMAINING /I 3.WAS TANK FILLED WITH 1AALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO APPLICANTS NAME WLEDGE, IS TRUE AND CORRECT (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# 3 11 Tn�2DTOB /s PERMIT NUMBER PERMIT APPROVED BV/DATE D PERMIT EXPIRATION DATE �� FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORo931BR4