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• to .- e co STATE OF CALIFORNIA � STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. EMARK;;O�;S+ NEW PERMIT ❑ RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE S TANK REMOVED WHERE TANK IS INSTALLED: Z4D �,ZN 7 F I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN B. MANUFACTURED BY: A OWNER'S TANK I.D.a �� D. TANK CAPACITY IN GALLONS: 19p C. DATE INSTALLED(MO/DAY/YEAR) . ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. EDIa REGULAR ❑ 3 DIESEL ❑ 5 AVIATIONGAS A. TOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM 90 EMPTY 7 PRODUCT ❑ tb PRUM EAIDED 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE DED 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.a: D. IF(A.7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALLTHAT APPLIES INBOX0 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALL I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER (Primary Tank) 9 BRONZE ❑ ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIORED 5 GLASS LINING F-1 e UNLINED UNKNOWN ❑ 90 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100X METHANOL? YES— NO— D 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A - CTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 7 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN A I 99 OTHER C. MATERIAL AND A U 7 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANRED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ T MONRORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPORMONITORINO❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUNDWATER MONITORING ❑ 5 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION ESTIMATED QUANTITY 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2. SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 VES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PmNTE9 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JU�RISmDICTION# �FACILITY# TANK PPPW' STATE I.D.# 'Zj L� LJ PERMITNUMBER PERMIT APPROVED SY+DATE PERMIT EXPIRATION DATE Ll 1 1 FORM B (9901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 0 /'' 0