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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �a COMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONc'CLOSE ONE REM ❑ 2 INTERIM PERMIT ❑, 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED ON BITE 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3S_ P I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# Q B. MANUFACTURED BY: C. DATE INSTALLED(MWDAYNEAR) _ ) ��. V D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED, P TEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 IL B. ❑ C. ❑ 18UN EVADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM 80 PTY 1 P UCT O 1b PREMIUM Ed d GASANOL ❑ 3 CHEMICAL PRODUCT UNLEADED 5 JET FUEL ❑ 7 METHANOL UNKNOWN 2 WA87E ❑ 2 LEADED 99 D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED OTHER (DESCRIBE IN ITEM D. BELOM C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF UBLE WALL E] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SIN WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E:]!—� 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑� 10 GALVANIZED STEEL ❑ 95 UNKNOWN W OTHER ❑ 1 RUBBER LINED 2 ALKYD LWWG 3 EPDXY LINING d PHENOLIC LINING C.INTERIOR :-1 5 GLASS LINING ❑'�NLINED ❑ LINING LJ ❑ 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑I 2TING a 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED'PLAST_K; PROTECTION ❑ 5 CATHODIC PROTECTION ❑✓B1 NONE ❑ BS UNKNOWN � 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOT BLE A. SYSTEM TYPE A U 1 SUCg4l!IW� A U 2 PRESSURE A U 3 GRAM A U 99 OTHER B. CONSTRUCTION A U 1 A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 9B OTHER C. MATERIAL AND A BARES E A U 2 STAINLESS STEEL A U 3 PO L VINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U t99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LBVE I IUH I NESS TESTING ❑ NONOORNG ❑ N OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VA99ZPATt5NITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATERMONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING 1 NONE ED95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAS SE (M AYHR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH / r 2-- SUBSTANCE REMAINING O 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 IPRixTEp d SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# 3 S I I L-2 15- ' PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY&PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. iOMXBIBAf uw ��.