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STATE OF CALIFORNIA • ' ' STATE WATER RESOURCES CONTROL BOARD W p UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B , o �Y CXtiXOXYX COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. LDB ARK ONLY F-1I NEW PERMIT F73 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED A OR FACILITY NAME WHERE TANK IS INSTALLED: ; f,, Ale ! I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D,a B. MANUFACTURED BY: © V N c C. DATE INSTALLED(MOI)AYNEAR) D. TANK CAPACITY IN GALLONS: :5,5 U ILTANKCONTENTS IFA-1 ISMARKED.COMPLETE ITEM C. to REGULAR �I 3 DIESEL a AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. F2WASTETILn ❑ UNLEADED rL-J'I 4 GASAHOL ❑ LEUM go EMPTY Llrl- In PREMIUM ET ❑ 3 CHEMOICAL PRODUCT ❑ 95 UNKNOWN ❑ METHANOL ❑ NLEADE2 LEADED 9gJOTHERL(DESCRIBE IN7ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER UNKNOWN SYSTEM F-12 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED L 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— F-1 1 POLYETHYLENE WRAP F-12 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION F-15 CATHODIC PROTECTK)N ❑ 91 NONEUNIWOWN ❑ 99 OTHER IV.PIPING INFORMATIO CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A Vl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A&A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p UNKNOWN q U 99 OTHER ❑ D. LEAK DETECTION 1 AUTOMATICLINELEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MHOTtRORIALL [:]99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR 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.ESTIMATED DATE LAST USER(MOIDAY/YR) 2.ESTIMATED QUANTITY OF o 3.WASTANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS IN MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTEO A SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# # STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE 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. /J ( FOROROG3IBR/