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► STATE OFCALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTE IM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED A I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: E S / 1/�� V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN � A. OWNER'S TANK I.D.# / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) �.2_ D. TANK CAPACITY IN GALLONS: T� II.TANK CONTENTS FA--p IS MARKED,COMPLETE ITEM C. C! A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUREGULAR N FADEDrL4 SEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �RODUCT 1b PREMIUM AHOL 7 METHANOL ❑ UNLEADED FUELO 3 CHEMICALPRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED HER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTE NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MA ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN R GU SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrImaryTank) ❑ 9 BRONZE ❑ 1 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBE R LINED ❑ 2 AL YD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIORLIN ❑ 5 GLASS LINING ❑ 6 UNLI D ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% M ANOL4 YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE F7 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UND GROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SECTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A V 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 SAFE STEEL A U 2 STAINLESS STEEL U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 CONCRETE U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U g GALVANIZED STEEL A U 10 CATHODIC PROTECTIO A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 A ITOMATIC LINE LEAK DETECTOR ❑ 2 LINETIGHTN STESTING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK X2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTINGem 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ETI AT DATE LAST USED(MO/ AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS IN MATERIAL? YES [:] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE 104COUNTY# JURISDICTION# FACILITY# TANK# PERMIT NUMBERPERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORBN4&RS 0 Lo- lD - 73