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• STATE OF CAUfORNIA is STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ro, . COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE ❑ e TANK REMOVED O 9 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 37 E, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) VI G D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11SMARKEO.COMPLETE ITEM C. RGDDIIE,SAHOL A ❑ t MOTOR VEHICLE FUEL 4 OIL B. C. [:] to UNELEADED ULAR 3 SEEL ❑ S AVIATION GAS ❑ 2 PETROLEUM 90 EMPTY ❑ 1 DUCT E:] 1b PREMIUMUNLEADE5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED g 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 A. TYPE OF �71 0BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 NGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 10091 METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 A.KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING 19 UNING 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 LZ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTHI CABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAV A U 90 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99-0THER'� C. MATERIAL AND A U 1 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 S CONCRETE A U 7 STEELWICOATING A U B 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ MpNROflINGL OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 YAP6R MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 9 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN 99 OTHER VI,TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USE jMO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �� SUSSTANCEREMAINING GALLONS INERTMATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNAW REI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# F3771 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �FOR0031&R4 C