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.50JaCG. 00 G" 1n STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B sG COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT LJ`6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLEDG r9 - � fZ I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.Q# If B. MANUFACTURED BY: (�'flr'�l fUu�S i,.a - I(\ D. TANK CAPACIN IN GALLONS: C. DATE'INSTALLED(MOlDAYIYEAR) ILTANKCO NTS IFA-11SMARKED.COMPLETE ITEM C. aREGULAR O 3 DIESEL ❑ 6 AVIATIONGAS MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. UNLEADED ❑ 4 GASAHOL LDI 1 PRODUCT ib PREMIUM ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY ❑ UNLEADED ❑ 5 JET FUEL3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW) )IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.%: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.ANDC,ANDALLTHAT APPLIES INBOX D ANDE ❑ 1 'BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER SYSTEM 2 SINGLE WALL ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC B. TANK g INYL CHLORIDE ❑ 7 ALUMINUM ❑ 47 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL UNKNOWN ❑ g9 OTHER ❑ 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC: LINING C.INTERIOR 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 700% METHANOL? VES_ NO— [::] I O_❑ 1 POLYETHYLENE WRAP F-12 COATING ❑ 3 VINYL WRAP [1] 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION gt NONE �5 UNKNOWN E] 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION [= E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A FABOVEGROMOOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER LYVINYL CHLORIDE(PVC)ACb 4 C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 PO ' FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL Wl COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICP ECTION U UNKNOWN A U 99 OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING ❑ 3 AWNROBING ❑ 99 OTHER _ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF VES [1] NO ❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THISFTS ORM HAS BEEN COMPLETED UNDER PENAL PE 'URY AND D TO tI PE BEST OF MY KNOWLEDGE, IS TRUE ANNDD+(CORRECT APPLICANNAME (PRINTED a SIGNATURE) , LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY.# JURISDICTION# FACILITY# �T TANK# STATE I.D.# I L 1 J �>-15al mM1T PERMIT EXPIRATION DA PERMIT NUMBER TE BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. THIS FORM MUST FILE THIS FORM WIT LOCAL AGENCY IMPLEMENTING THE UNDERGROUND it tGE TANK REGULATIONS FOR00348 R5 FORM B (1291)