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a � efsoua ey eo STATE OFCAUFORNIA ^e STATE WATER RESOURCES CONTROL BOARD i '9 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W "tee \� 9 a �n4�onrVn COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 9 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 o G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.i B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: O ILTANKCONTENTS IFA-11SMARKED•COMPLETE ITEM C. 1-=LAR p, ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ DED ❑ 3 DIESEL ❑ e AVIATIONGAS ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ><2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STOREDO O a?Wa SfG C.A.S.i: O-j III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXESA,B,AND C,ANDALLTHATAPPLIES INBOX DANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �X 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) E:] 99 OTHER B. TANK 41AJ�1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL {{LL�J�J 5 CONCRETE S POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP (PdmaryTank) ❑ B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING �S UNLINED ❑ 95 UNKNOWN E:] 99 OTHER LINING Y IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ N025, D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION rK 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILLAND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AV BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U a CONCRETE A U 7 STEELW/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 A MONRORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATERMONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING X91 NONE L_j 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE ST USE4(MO/DAY/YR) 2.ESTIMATED QUANTITY OF w 3.WAS TANK FILLED WITH S SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLIAN CTS NA ME DATE (PRINTED B SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Ae c, TE C�OUNTY# JURISDICTION# FACILITY# TANK# STATE LDAyJy � 0 I 0 0 16 M 111 k PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS v 1w"6 FORM B (12-911 •'D J� —95 9G FOR00346R6