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STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD iv UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED ONSITI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDW IV D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IzA I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.• B. MANUFACTURED BY: /. w./s C. DATE INB LED(MODAYNFAR) D. TANK CAPACITY IN GALLONS: II. TANK ONTENTS IFA-115MARKFO.COMPIPTF ITFMC. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C la REGULAR n 3 DIESEL O 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ W EMPTY 1 PRODUCT UNLEADED 4 GASAHOL ❑ 1DUNLEAI. LJ ❑ 7 METHANOL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 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. s: III. TANK CONSTRUCTION MARK nNFITFMONIY IN RnYFR A R AM1R ANh GII TYGTERRI ICC I. onvn none A. TYPE OF ❑ 1 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 ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER LEAK DETECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9/ NONE F-] 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR IT IF I INOFRGRnI INn RnTH IF ew l Item F A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 89 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 CORROSION PROTECTION A U A U A U 1 RARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 8 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVCIA U 7 STEEL W/COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE B 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 01 MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE 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. ESTIMATE D�T4LAST U.f fM DAY/YR) 2. SUBSTANCE REMAIESTIMATED QUANTININGF GALLONS S WASTANK FILLED NERT MATERIALITM YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PRINTED a SIGNATNREI LIJUAL AUI:NL:Y USE UNLY THE TATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# ,� coffin JURISDICTION " FACILITY T^ PERMIT NUMBER L,`L11-PIGEIRMIT APPROVED BY/DATE PERMIT EXPIRATIONDATEIDATTEE ll�1J FORM 8 (7.91) 1 HIS I-UHM MLI tit AUW MMPANIEU BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED �