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• STATE OFCALIFORNIA • "esw+ es c° t� STATE WATER RESOURCES CONTROL BOARD sy 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-MSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED 1 {I Li DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r'd J d- vPN S " Cl �'e-I-� C I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYA'EAR) C D. TANK CAPACITY IN GALLONS: kh �EEE II.TANKC EMS IFA-I IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OILB. ❑ IAUNLEADED REGULAR � 3 DIESEL ❑ 8 AVIATIONGAS 712 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 10UNLEAIDED 5 JETFUEL 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADE(D'_ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX 1 UBLE ALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ SYSTEM 2 SPOCE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANKBARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED 2 ALKYD LINING ❑ 3 OXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING 8 UNLINED 95 UNKNOWN 99 OTHER LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ r D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ ISERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC C. MATERIAL AND (PVC) U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 8 100% M THANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 O R D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR Q 2 LINE TIGHTNESS TESTING L 31 RS UL gg OTHER u MONITORING V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNRI, 2.ESTIMATEDOUANTITYOF / 3.WASTANK FILLED WITH YES ❑ NO SUB STANCE REMAINING l�aC) GALLONS INERT MATEflIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PNNTFO a SIGNATURIS DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# FEE PERMIT NUMBER PERMIT APPROVED 8Y/DATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00316R4 0 0