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a�Py STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W mom, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B °.ci.orJ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY jJ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 77❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I ©/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Tu I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.a S. MANUFACTURED BY: C DATE INSTALLEO(MO/DAYNFAR) D. TANK CAPACITY IN GALLONS: BMJ ILTANKCO S IFA-11SMARKED.COMPLETEITEMC. A i MOTOR VEHICLE FUEL E] 4 OIL 8. C. UNGLEADEO ® 4 GASAHOL ❑ 8 AVIATION GAS E—] 2 PETROLEUM F780 EMPTY 1 PRODUCT ❑ lbIDED PREEMMIIUM 6 JET FUEL E] 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE O4LEADED Ed 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A A 0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALLTHAT APPLIESIN BOX ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 96 UNKNOWN A. TYPE OF ❑ 99 SINGLE WALL OTHER SYSTEM 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 1 SARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL s CONCRETE ❑ a POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP ❑ (PrimarYTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 CLASS LINING ❑ 6 UNLINED L; I. IOaOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNIOJOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE 7LEAKD PE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER TION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE N A U S ALUMINUM A U B CONCRETE p U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP N A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p UNKNOWN A U 99 OTHER CTION ❑ 1 AUTOMATIC LINE LEAK DETECT'1R LINE TIGHTNESS TESTING ❑ O AgN00RNG ❑ OTHER V.TANK LEAK DETECTION ❑ 1 VI CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 6 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING 8'TANK ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ 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❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT' APPLICANTS NAME DATE IPFINTFG d SIGNATOREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# r TANK# STATE I.D.# nj n 0 / IZ4 I I I S 1-317- I PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE /L.� 74- FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE/Dv Al L-2