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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EX<TANK SYSTEM MARK'ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE < jCS'ID O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY TANK CLOSURE ❑ 8 TANK D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: )q Q�,p FAG.. 1.1D. OS 4 8 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O.,t _UtlL.� I B. MANUFACTURED BY: C. OATS INSTALLED(MO/DAY/YEAR) 0. TANK CAPACITY IN GALLONS: \ OV "7-7 X01000 11.TANK CONTENTS IFA-1 IS MARKED.COMPLEmITEM C. =u�- EL t MOTOR VE141CLE FUr 4 OIL a REGULAR � u B' I C. ❑� UNLEADED �--: 3 DIESEL _ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 30 EMPTY �vrt PRODUCT ❑ UNLEADED M ! 5 JET FUEL 7 METHANOL UNLEA3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED gg OTHER (DESCRIBE !N ITEM 0. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF L__: 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑1e-2 SINGLE WALL I❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL I❑ 2 STAINLESS STEEL F y�3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PL AST:C MATERIAL ❑ 5 CONCRETE J 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%ME-tHANOL COMPATIBLE'N/FRP (Primary Tank) !-1 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER j 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C ' LINING 5 GLASS LINING ❑V-- UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ 0.CORROSION —? 1 POLYETHYLENE WRAP ❑ 2 COATING I _ 3 VINYL WRAP 1i 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 77, 5 CATHOOICPROTECTICN ❑ 91 NONEj', 95 UNKNOWN ❑ 99 OT14ER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.30TH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 02 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Ao 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION F-;?'l AUTOMATIC UNE LEAK DETECTOR CI.r UNE TIGHTNESS TESTING ❑ iaKrrORING ❑99 OTHER V.TANK LEAK DETECTION I�1 VISUAL CHECK 1 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 iNTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER Vl.TANK CLOSURE INFORMATION ESTIMATED DATE LAST USED(MO/OAY/YR) 2-ES71MATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 6 SIGNATURE) DATE 'J\�V'j of LCCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO NUMBERS BELOW —� ACOUNTY x JURISDICTION x FACILITY x TANKS STATE 1.D.A U" PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FCRM 3 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �� FCF00338-:5