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� uqe STATE OF CALIFORNIA 4 STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR ECH TANK SYSTEM. MARK ONLY Q 1 NEW PERMIT Q 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK 1S INSTALLED: It 31 /l f N ✓F I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNFR'S TANK I.D.fY 1! B. MANUFACTURED BY: L] C. DATE INSTALLED(MOIDAYNEAR) j�lJ D. TANK CAPACITY IN GALLONS: II.TANKC NTENT$ IFA-11SMARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL Q 4 OIL B- C. 1AUNLEA ED REGULA 3 DIESEL ❑ 8 AVIATION GAS MILIMR H 4 OASA1iOL i 1 2 PETROLEUM Q 80 'EMPTY Ly-} PRODUCT ❑ 1bUNEEADEO ❑ 5 JET FUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT Q 95 UNKNOWN 2 WASTE Q 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. 1F(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A,S.II: 111, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D A. TYPE OF F�jxDOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER Q 95 UNKNOWN SYSTEM [4,] 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER SINGLE WALL Q 1 BARE STEEL ❑ 2 STAINLESS STEEL Q 3 FIBERGLASS Q 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE Q 6 POLYVINYL CHLORIDE Q 7 ALUMINUM Q8 IDM. METHANOL COMPATIBLE WIFRP ❑ LJ (PrlmeryTenk) ❑ 9 BRONZE Q 10 GALVANIZED STEEL 96 UNKNOWN ❑ 99 OT1415R ❑ 1 RUBBER LINED Q 2 ALKYD LINING ❑ 3.EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING ❑ 8 UNLINED �6 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO� D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING Q INYL WRAP Q A FIBERGLASS REINFORCED PLASTIC PROTECTION Q 5 CATHODIC PROTECTION Q 91 NONE Fn 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC-) FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 IW% METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTErCTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 I TO %INa 0 99 OTHER V.TANK LEAK DETECTION,,-' ❑ VISUAL CHECK 2 INVENTORY RECONCILIATION Q3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING Q5 GROUNDWATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING Al NONE El 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO�DAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED d SIGNATVRF) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION M FACILITY# TANK A STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE r�r y' q FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORORi4B Ra r.