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P ti. STATE OF CALIFORNIA ' STATE WATER RESOURCES CONTROL BOARD .� UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑;7PERMANE;NTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ NK REVEDG" DBA OR FACILITY NAME WHERE TANK IS INSTALLED: qr k I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN B MANUFACTURED BY. A. OWNER'S TANK I.D.A m—0 D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAY/YEAR) 11.TANK,CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. ❑ iaREGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS C 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL A. 1 ❑ 2 PETROLEUM ❑ 80 EMPTY ❑PRODUCT ib PREMIUM UNLEADED ❑ '. JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALLTHAT APPLIES IN BOX D V DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ ss OTHER SYSTEM SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 8. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100'/ METHANOL COMPATIBLE W/FRP MATERIAL ❑ s CONCRETE ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER ❑ 5 GLASS LINING LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO -- ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ?/VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION L—iY9�5 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9/ NONE is IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE FCC. M TYPE �Al CTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER RUCTION NGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A(U 5 UNKNOWN A U 99 OTHER IAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE OSION A U 5 ALUMINUM p U 6 CONCRETE A U 7 ST Ej-W/COATING A U 6 100°/ METHANOL COMPATIBLE W/FFP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U UNKNOWN p U 99 OTHER A D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONIT?INTERSTITIORINGL ❑99 OTHER_ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION3.WAS TANK FILLED WITH YES Gl NO ❑ ::::�SUB�STANCE UANTITY OF GALLONS INERT MATERIAL? 1.ESTIMATED DATE LAST USED(MO/DAY/YR) REMAINING THISFORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE E IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 8 SIGNATURE) LOCAL AGENCY USE QNLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# ¢L L COUNTY# JURISD�ICTI❑ON# FACILM# qGSTATE I.D.# Ld .3 r PERMIT NUMBER PERMIT APPROVED BY/DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORMA,UNLLEE�S ENT FORMA HAS BEEN FILED� � FOROMB R4 FORM B (9-90) �/ L J ` ( 5