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• �.uu^c¢T STATE OF CALIFORNIA Mme" CO: STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B v; •iy; . COMPLETE A SEPARATE FORM FOR EA;H TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT $ CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERM %I ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1,375- � � 95-37.6' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A I S. MANUFACTURED BIftft e C. DATE INSTALLED(MO/DAY/YEAR) (7( D. TANK CAPACITY IN GALLONS: II.TANK NTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. I MOTOR VEHICLE FUEL ❑ 4 OIL g, C ❑ 1a REGULAR 3 DIESEL ❑ g AVIATION GAS UNLEADED r72 PETROLEUM ❑ 80 EMPTY Clel PRODUCT ❑ lbPREMIUNLEAUM 4 E] 5 GASAHGASAHIET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER {DESCRIBE IN ITEM 0. BELOYI) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.e III. TANK CONSTRU6TION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VA LTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 9g OTHER ❑ 1 RUBBER LINED ❑ ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C INTERIOR UN NG ❑ 5 GLASS LINING CZ 0 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_, NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL ArU 2 DOUBLE WALL A U 3 LINE4 TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)JCU> FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 IMCNN S I IAL gg OTHER V.TANK LEAK DETECTION RORING ❑ f ❑ i VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING /Ir/�/ ❑ 6 TANK TESTING Z7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTS NAME (PRINTEO&SIGNATURE) DATE dQ. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D. �� ❑❑ D y�2-�'�1y PERMIT NUMBER PERMIT APPROVED BY/OPERMIT 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. FOR0=11-PA