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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD � UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ry i o' COMPLETE A SEPARATE FORM FOR E H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 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 IS INSTALLED: 15'33 AF• Gi t7 s I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# C2 7 S. MANUFACTURED BY: Celt C. DATE INSTALLED(MODAY/YEAR) �� D. TANK CAPACITY IN GALLONS: /V DOO II.TANKC NTENTS IFA-11S MARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ 18 REGULAR DED 3 DIESEL ❑ e AVMTION GAS A ❑ 2 PETROLEUM Q BO EMPTY �waoDCT ❑ lb PREIUMUNLEADE5 JTSFlIEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCTO % UNKNOWN ❑ 2 WASTE O 2 LEADED 8 99 OTHER (DESCRIBE IN ITEM D. BELONI 0. IF(A1)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 ❑] 1/ )BLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM � 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK v 1 BARESTEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O B POLYVINYL CHLORIDE a 7 ALUMINUM O 8 103% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL % UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED O 2 ALKYD LINING a 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INLJNI GR F-1GL 5 ASS LINING UNLINED % UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP I�I 2,WATING 3 VINYL WRAP F7PLASTIC4 FIBERGLASS REINFORCED PLASTIC PROTECTION O 5 CATHODIC PROTECTION ( 91 NONE % UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A<J�) A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A&<SI A U 2 DOUBLE WALL A U 3 LINED TRENCH A U % UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1<39E-§T A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U W OTHE D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3INT RS AL OTHER MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ % UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 3�`7.�. SUBSTANCE REMAINING GALLONS INERT MATERIAL? Ell THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IVWNTEDa SiGxxTDRID DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# W •S7aGK IS STATE I.D.# 3 yI I I/ o 7 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. FOROWIBAt r