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STATE OF CALIFORNIA 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 ❑ S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SL TF ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT = S TEMPORARY TANK CLOSURE ED- B TANK REMOVED C DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (.�" ,i 7 F., F)l.tii 7ix � I. TANK DES D.ON COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN " _ _ A. OWNER'S TANKNK 1.LD. B. MANUFACTURED BY: - - C. DATE INSTALLED(MO/DAY(YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCO -ENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ laEGULAREADEO 3 DIESEL ❑ S AVIATIONGAS E-] 2 PETROLEUM ❑ 80 EMPTY ❑V'r 1'PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL ❑ UNLEADED [:j 5 JETFUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) � D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 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 �❑ i1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN U SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LININGa UNLINED LINING ❑ ❑ �L 9S UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �NKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL p U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 1 BARE STEEL q U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U S 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 ❑ 3 MONRORING ❑ OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ S TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 1❑985 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTII� SED(TED TE AST UO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH ?j --- — G SUBSTANCE REMAINING IM GALLONS INERTMATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER�j,/ Y,AND TO TH nT OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME" - t IPRINTEDaSIGWlT11RE) V^\ I / C LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 1� ' - TANK# ( ( I STATE I.D.# m = .2 H; , -9 s PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) FDP091d&R6