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esaw � co STATE OF CALIFORNIA �� ^, STATE WATER RESOURCES CONTROL BOARD w ,p� o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ?n � on NDN COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIT] MARK ONLY ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 2 STAINLESS STEEL TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3z a E ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE �+❑ X88 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MONAYWEAR) D. TANK CAPACITY IN GALLONS: I ANKCONTENTS IFA( ISMARKED COMP ITEMC I. T -REGULAR A ❑ 1 MOTOR VEHICLE FUEL IV4 OIL B. o 3 DIESEL 8UN LEADED ❑ 4 GASAHOL ❑ 8 AVIATION GAS C. ❑ 18 ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT E::]ibPREMIUMUNLEADED F-15 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 96 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S.0: •ruw ^^&I0T0IIPTVYA1 vicee G Bunn eNn All TNATAPPIIFRINROYO IV DIa1Nr IMFnRMATInN OIRnIE A IFARDVFC.RDIINDOR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE ❑ 1 DOUBLE WALL❑ 3 GLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SINGLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FflP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR❑ 5 GLASS LININ UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER LINING 10 CATHODIC PROTECTION A U 95 UNKNOWN Aom OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINETOwTNESSTESTING 9 iNTLF3TITIAL OTHER MONITORING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES _ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E-15 CATHODIC PROTECTX7N 1 NONE ❑0.5 UNKNOWN ❑ 99 OTHER IV DIa1Nr IMFnRMATInN OIRnIE A IFARDVFC.RDIINDOR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A & PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENOH A U 95 UNKNOWN A U 99 OTHER PERMIT APPROVED BYIDATE AU 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL CO (BLE /FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN Aom OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINETOwTNESSTESTING 9 iNTLF3TITIAL OTHER MONITORING I. TAN AK DETECTION I 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 INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAV/VR) 2SUTBSTATED NCEREMAITY O.ININGF GALLONS 3WA INERTMATERIALTANK FILLED 7N 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW i COUNTY# JURISDICTION# FACT TANK# STATE I.D.# c PERMIT NUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT gFORM �A-yHAS BEEN FILED. FOR0034&B4