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• STATE OF CALIFORNIA • ° e STATE WATER RESOURCES CONTROL BOARD �+ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. EDBAOR NLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION M ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED ONSITE ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / FACILITY NAMEWHERE TANK IS INSTALLED: 2A4.llJ I'z,9 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# On a B. MANUFACTURED BY: U K C. DATE INSTALLED(MO/OAVIVEAR) I D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. LIF(A.1) OTOR VEHICLE FUEL ❑ q OIL B. 1a REGULAR I� ETROLEUM ❑ ❑ Ec. ❑ UNLEADED }.� 3 DIESEL ❑ 6 AVIATIONGAS ADED BO EMPTY 1 PRO ❑ 1b PREMIUM LJ 4 GASAHOL HEMICAL PRODUCT 96 UNKNOWN ❑ 2 WAS2 LNELLEA ED ❑ 5 JETFUEL ❑ 7 METHANOL OT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ ❑ 89 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX LTANK ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 2 SINGLE WALL 95 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER :E] 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM BRONZE ❑ e 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING C.INTERIOR ❑ ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED B5 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7NO— D. ❑ 99 OTHER YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ��--��//95 UNKNOWN ❑ 4 FIBERGLASS REINFORCED PLASTIC 54 ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p U 2 PRESSURE A U 3 GRAVITY A® 99 OTHER u I� B. CONSTRUCTION A U 1 SINGLE WALL p U 2 DOUBLE WgLL A U 3 IN TRENCH p 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL p U 2 STAINLESB STEEL A U 3 POLYVINYL CHLORIDE PVC CORROSION A U S ALUMINUM p U 6 CONCRETE ( lA U 4 FIBERGLASS PIPE PROTECTION A U 9 GALVANIZED STEEL A U 7 STEEL W/COATING p U 8 100% METHANOL COMPATIBLE WIFRP A U 10 CATHODIC PROTECTION A�95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ / AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 31MERSTRIAL V.TANK LEAK DETECTION MONITORING �� OTHER 1 kill ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GR=WATEgMONITOgING❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE �95 UNKNOWN ❑ 99 O VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF V SUBSTANCE REMAINING I/u4C GALLONS 3 W EAS ARTMATERINK FILLED AL17H YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, lS TRUE AND CORRECT APPLICANTS NAME (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION FACILITY# STATE I.D.0 �„� T r O TANK# PERMIT NUMBER I-J�V/PEIRMIT APP)—q-OVELD BLVJ/Dg7E PERMIT E%PIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348-134 6 0 1`2 1