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( STATE OF CALIFORNIA it . ''•.•••� + STATE WATER RESOURCES CONTROL BOARD ;I UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I + { MARK ONLY ❑ 1 NEW PERMIT -73 RENEWAL PERMIT ❑ 5 CHANG6!OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REWO%SZ I DBA OR FACILITY NAME WHERE TANK IS NS ABED: I. TANK DESCRIPTION COMPLETE_Al I-vs- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.a B. MANUFACTURED BY. lit ,� . F fF MOMAY/ EAR1 TANK CAPACITY IN GALLONS:DATE INSTALLED( -7o-- 11. . II.TANKCONTENTSIFA-1 IFA•,ISMAt,K�.^" �LETEITEMc. E A 1 MOTOR VEHICLE FUEL A OIL B. I1■REGULAR 3 DIESEL C. ❑'3 ❑ £ AY:ATIDN GAS i UNLEADED 4 GASAHOL ❑ 2 PETROLEUM ❑ in EMPTY 1 PRODUCT r7[11111 PREMIUM ❑ ; METHANOL ,- ❑ UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE 2 LEADED 1. ❑J � 99 OTHER (DESCRIBE n !^M D. BELOW) 0. IF(A.11 IS NOT MARKED. ENTER NAME a Ca57ANCE STORED I} + C.A.S.s la III. TANK CONSTRUCTION MARK ONE i7-SV ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AA'D E f A. TYPE OF ❑ I DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ��^ ❑ 95 UNKNOWN I. SYSTEM 2 SINGLE WALL J a SECONDARY CONTAINMENT (VAULTED TANK1 ❑ 99 07-HER B. TANK ❑ 1 BARE STEEL 1 1 2 STAINLESS STEELS FIBERGLASS D 4 STEEL CLAD Wr FIBERGLASS tiEIN=D+:'e0 PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 5 POLYVINYL CHLORIDE ❑ 7 ALUMINUM' ❑ B 100% METHANOL COMPATIBLE N'=R? (PrimarYTank) ❑ 9 BRONZE ( 10 GALVANIZED STEEL ❑ 93 UNKNOWN O 99 OTHER F7 1 RUBBER LINED ❑ 2 Al+n D LINING ❑ 3 EPDXY LINING a I PHENOLIC LINING C.INTERIORI'. LINING ❑ 5 GLASS LINING I 6 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COV=A"'S E WITH i00% METHANOL? YES_ NO ' D,CORROSION ❑ 1 POLYETHYLENE >ti;{= `I 2 COATING ❑ 3 VINYL WRa ❑ s FIBERGLASS REINFORCED PLASTIC li PROTECTION ❑ 5 CATHODIC PRQ`cCTIC1 '•❑ 91 NONE 5 UNKNOWN_ ❑ 99 OTHER i1 E.SPILL AND OVERFILL SPILL CONTAlNM=-NT:%STALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR} IV.PIPING INFORMATION CIAC:E A 1=ASCVE GROUND OR U IF UNDERGROUND,BOTH IF APPL IICABLE xl A. SYSTEM TYPE A V1 SUCTION A U 2 PRESSURE A U 3 GRAVITY jl A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE ",Aa A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN A U 99 OT1+ER C. MATERIAL AND A U 1 BARE S7Ec'L A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U • FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING. A U 9 100% ME114ANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVAN'I=-D STEEL A U 10 CATHODIC PROTECTION ALIP9S rUNKNOWN A U f99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LSH_LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING R ❑ 3;�MDHRORMG L� I 99 OTHER t V.TANK LEAK DETECTION It ❑ 1 VISUAL CHECK ❑ 2 INVENTOPY RECONCILIATION ❑ 3 VADCZE MONITORING I < AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITOR ING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95!l UNKNOWN ❑ 99 OTHER , I VI.TANK CLOSURE INFORMATION I` 1.ESTIMATED DATE LAST L'ScD MOIDAYIYR} 2.ESTIMATED QUANTITY OF I J.[3.WAS TANK FILLED WITH YES ND SUBSTANCE�"EMAIN'ING _GALLONS I INERT MATERIAL? c., T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THEA qST O1=Me KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAMEV (� DATE IPRINT 5 GNATURE / 1..'�_r i I J r} 1 LOCAL AGENCY USE ONLY THE STA'TE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW;F COUNTY A JURISDICTION# FACILITY M ' TANK 9 STATE I.D.# ❑ 1 .1 17TI17M PERMIT NUMBER PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE f !I THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B 112,911 - FORD: "6