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STATE OF CALIFORNIA °` co STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `'�•_�•" MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT7 PERMAN ONE ITEM ❑ 2 INTERIM PERMIT s AMENDED PERMIT 5 CHANGE OF INFORMATION E::] Y CLOSE SITE ❑ e TEMPORARY TANK CLOSURE ❑ 8 TANK REM VED O OBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN Q A. OWNERS TANK I.D.8 ` B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) ctD. TANK CAPACITY N GALLON$: l0 000 II.TANK CO ENTS IFA-11SMARKED,COMPLETE ITEM C. A. EVI MOTOR VEHICLE FUEL ❑ M OIL B. C ❑ la REGULAR 3 DIESEL ❑ 8 AVIATIONGAS UNLE❑ DED 2 PETROLEUM ❑ 80 EMPTY (; I PRI T ❑ ib PREMIUM a GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNM40WN ❑ 2 WASTE F72 LEADED99 5 JETHER 9D OTHER (DESCRIBE N ITEM 0. BELOW) D. F(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 0.A.S.x III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM EP2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTS ANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmayTwk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 OXY LINING ❑ d PHENOLIC LINING C.INTERIOR NGfl❑ 5 GLASS LINING ❑ 8 UNLINED 96 UNKNOWN ❑ oo OTHER 19 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 .PoLVETHYLENE WRAP ❑ 2 "n"G ❑ 3 V L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION O 5 CATHODIC PROTECTION a 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGROUNO.BOTTIIFAPPLICABLE 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 A U 2 DOUBLE WALL A U 3 LIN TRENCH U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND " U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 ;WCOATING A U 8 100% METHANOL COMPAT19lEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECT ION UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LINE TXiHTNESS TESTING ❑ 3 UL 99 OTHER MONITORING ❑ //, V.TANK LEAK DETECTION / ❑ 8 TANK TESTING ❑ 7 NTERSTORY ITIALMONROIRING� ❑ 91VAPOR NONE 95 95 UTOMATIC NKNOWN TANK GAUGING 99 OTHER D WATER MONITORING VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES L] No THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (MW DAa ATUAE) 12— LOCAL 2LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW !.T/ COUNTY 8 JURISDICTION 8 FACILITY 8 TANK 9 STATE I.D.# 101(91010110F41 PERMITNUMBER m(x r PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM a (9.90) 1 THIS FORM MUST BE ACCOWANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM8A41