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• STATE OF CALIFORNIA • re°pO," ° °o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FORE TANK SYSTEM C1liOINi E;;; 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ e TANK REMOVED ME WHERE TANK IS INSTALLED: rS/ P, S offs A7�e SW t I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# O .2--- B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYIYEAR) (J ��' IL D. TANK CAPACITY IN GALLONS: /0" U tid II.TANKC TENTS IFA-11S MARKED,COMPLETE ITEM C. A . MOTOR VEHICLE FUEL ❑ 4 OIL B. C to REGULAR 3 DIESEL PETROLEUM 80 EMPTY PRODUCT ❑ 7b PREMIUM ❑ 4 UNLEADED GASAHOL ❑ 8 AVIATION GASCHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASE ❑ UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW)NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,S.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL ❑ 95 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ % OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL GLASS ❑ 4 100%STEEM LAD W/FIBERGLASS REINEWIFRP PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORID::::INUM(PrimaryTank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL NOWN ❑ 99 OEgETHANOL COMPATIBLE WiFRP ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING C.INTERIOR ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED d96 UNKNOWN El 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN ❑ gg OTHER W.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE =EE::] PE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY TION A U 1 SINGLE WALL A U 2 DOUBLE WALL A 98 OTHER A U 3 LINED TRENCH A U 95 UNKNOWN q U 99 OTHER AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVCN A U 5 ALUMINUM ( IA U 4 FIBERGLASS PIPE A U B CONCRETE I U 7 STEEL 5 COATING A U B 100% METHANOL COMPATIBLE W/FRP N A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION q U g5 UNKNOWNCTION 0 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING IA U 99 OTHER_ 3 MONITORING 0 98 DTHE IA V.TANK LEAK DETECTION FE' 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 81 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST l�6ED(}1S1/ AYNR) 2.ESTIMATED QUANTITY OF ( [/6 SUBSTANCE REMAINING3•WAS TANK FILLED WITH ❑ _GALLONS INERT MATERIAL? YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# STATE I.D.# TANK#�Q rd-dx)i F� PERMIT NUMBER�� PERMITAPPROVED BV/DATE 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. 0 //� FOR001B-R4