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..i slow STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM. :y FMA;RKONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT❑ 2 INTERIM PERMI7 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSUREO e TANK REMOVED CILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN #� A. OWNER'S TANK I.D.# B. MANUFACTURED BY: /i 6 O DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: LCC` II.TANK CONTENTS IFA-115MARKEO,COMPLET A. 0 1 MOTOR VEHICLE FUELL6d-4 OIL B. ❑ Ie REGULAR On�j 3 DIESEL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PR T C UNLEADED LJ 4 GASAHOL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN WASTE ❑ IIIPREMIUM ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 2 LEADED E-1 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(0.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOXD ANDE 1 LISLE WALL 3 SINGLE WALL WITH EXTERIOR LINER A. TYPE OF ❑ SYSTEM 2 5 LE WALL ❑ Ell 95 UNKNOWN 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK EP41 BARE STEEL ❑ 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ �MINUM � 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ D BRONZE O 10 GALVANIZED STEEL LW95 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED LINING ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 G ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEMTYPE A U 1 SUCTION A U 2 PRESSURE A A U 99 OTHER S. CONSTRUCTION A U 1 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 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER EMS IAL V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 V EMONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST U ( / A NR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING 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 IPRINTEG 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# a4V7Vrr1 a7 STATE LDA F301 = © �Im PERMITNUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATION_DATE �LLJ FORMS (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. - F011,