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fppOVR f C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W tl�I e UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ;� a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -370a + I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.%:R IB. MANUFACTURED BY: av • C. DATE INSTALLED(MO/DAYNEAR) l D. TANK CAPACITY IN GALLONS: O TANK CON IhNI, IFA -1 IS MARKEDCOMPUeFE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. / C. ❑ IaUNLEADED REGULAR❑ 3 DIESEL ❑ g AVIATIONGAS ❑ 4 GASAFIOL ❑ 2 PETROLEUM ❑ 80 EMPTY i PRODUCT ❑:PREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. %: 111 TAMIZ T`TIMCTGIICTInM HAoVnNC L=UANIVINRDVP9 A R ANDC. AND ALL THAT APPLIES IN ROXD IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. ❑ I DOUBLE WALL [V::]3 INGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER CONSTRUCTION BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ s CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimeryTmk) ❑ 9 BRONZE ❑ 70 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING 7 STEEL W/ COATING A B 100% METHANOL COM AT LE WIFRP PROTECTION A U 9 GALVANIZED STEEL IS LINING MATERIA COMPATIBLE WITH 100% METHANOL? YES_ NO— A U 95 UNKNOWN 99 OTH vajamedgg D. CORROSION ❑ I 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 IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A_U 1 SUCTION 02 PRESSURE A U 3 GRAVITY A U 9B OTHER B. CONSTRUCTION A& SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER A U I BARESTEEL 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 B 100% METHANOL COM AT LE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN 99 OTH vajamedgg D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIALOTHER TANK VAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 6 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION L ES]IMAVD DATE LAST USED(MO/0AY/YR) 2. ESTIMATED I REMAININGQUANTTY GALLONS 3 WAS INERTMATERIALWITH ? YES ❑ NO E7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FA TANKS STATE I.D.# m -3 PERMIT NUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. ElIIT/ ` S..0i FOR9971SM