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• IJV . STATE Of CALIFORNIA . ms's'",-•••....�nor STATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM MARK ONLY1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS' TE ONE ITEM E�12 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED IA 08A OR FACILITY NAME WHERE TANK IS INSTALLED: 'L�j�� - —46� 9 33.76. 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK L 0.t B. MANUFACTURED BY: ff f.7 C. DATE INSTALLED(MOrOAY/YEAR) � L/�, � D. TANK CAPACITY IN GALLONS: / 7,000 II.TANK 92NTENTS IF A-1 IS MARKED.COMPLETE ITEM C. n A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑-1 o, UNLEADED �-.{ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY t v PRODUCT fjf 1C PREMIUM I._J 4 GASAHOL ❑ 7 METHANOL UNLEAOE❑ 3 CHEMICAL PROOUCT ❑ 95 UNKNOWN ❑ 2 WASTE «❑111 2 LEADED D H 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a Ill. TANK CONSTR4eTICIN MARK ONE ITEM ONLY IN BOXES A.8.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 (VAULTED TANK) 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNK40WN 99 OTHER 1 RUBBER LINED 2 O LINING 3 EPDXY LINING 4 PHENOLIC LINING O.INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP U�r4 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 A u 2 PRESSURE A U 3 GRAVITY A u 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL ACU)2 DOUBLE WALL A U 3 LINED 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) (U 4 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 PROTECT ION 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 OETECTOR 2 LINE TIGHTNESS TESTING IN 1MroRING 0 9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING cit 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION L ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FLLEOWITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW W COUNTY# JURISOICTION x FACILITY x TANK 9 STATE I.D. ETI 1 101,11 v 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE Fj/�- FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FCRCa348.;U