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STATE OF CALIFORNIA � STATE WATER RESOURCES CONTROL BOARD A" UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °•,,. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ ❑ 5 CHANGE OF INFORMATION 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE01 7 PERMANENTLY CLOSED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -� a TANK gEMOVED I, TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN FAWNERS TANK I.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: IIJA�N_K�CONTENTS IFA-11S MARKED,COMPLETE ITEM C. vvv A. III 1 MOTOR VEHICLE FUEL ❑ 4 OIL B IS REGULAR f�❑'i�2 PETROLEUM ❑ 80 EMPTY ��--yy C ❑ UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS `o yfl 1 PRODUCT ❑ 1b PREM[UM ❑ 4 �SAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN /❑ 2 WASTE I;le2 LEADED ❑ 5 JETFUEL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARKONE ITEMONLYINBOXESA,B,AND C.AND ALL THAT APPLIES IN BO%D ANDE O A.S.a: A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2 SINGLE WALL ❑ 4 ❑ 95 UNKNOWN SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL I�'� ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ (PrimaryTank) ❑ 9 BRONZE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ ❑ 2 ALKYD LINING C.INTERIOR 1 RUBBER LINED ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ><6 UNLINED ❑ 99 OTHER 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL S VES_ No D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING PROTECTION 5 CATHODIC PRO ❑ 3 VINYL WN ❑ 9 FIBERGLASS REINFORCED PLASTIC ❑ TECTION 91 NONE E]95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENiINSTALLEO(YEA R) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH ETION EQUIPMENT INSTALLED F APPLICABLE YEAR) A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE B. CONSTRUCTION A U 3 GRAVITY A U 99 OTHER SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A C. MATERIAL AND A 1 DARE STEEL 99 OTHER CORROSION A 5 ALUMINUM A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE PROTECTION A U e CONCRETE U 7 STEEL 5 COATING A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTI A U 95 ON A U B 100% METHANOL COMPgTIBLE W/FRP D. LEAK DETECTION ❑ 1 AUTOMAT ❑ 2 LINE IC LINE LEAK DETECTOR UNKNOWN A U 99 OTHER TIGHTNESS TESTING 3 A V.TANK LEAK DETECTION MDNIroRINc 99 OTHER ❑❑ 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 1.ES ATE DATE LAT ED IMO/DAYNR) 2.ESTIMATED QUANTITY OF k SUBSTANCE REMAINING '4L 0 3.WAS TANK FILLED WITH 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 (PRINTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. STATE I.D.# NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �L 2 COUNTYN JURISDICTION# FACILITY� /� / � TANK# [PERM:ITNUMBER HERMIT APPgOVEO BY/DATE PERMIT EXPIRATION DATE �'- THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. (/ FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOROWO&R6 / I A�Lj