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(3 STATEOFCAUFORMA .• STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM •Cw{,-Ow MARK ONLY ❑ 1 NEW PERMIT7 PERMANENTLY Y REM 2 INTERIM PERMIT❑ ❑ 3 RENEWAL PERMIT A AMENDED PERMIT ❑ 5 CHANGE Of INFORMATION ONE ENTLY CLOSED ONSITE ❑ ❑ e TEMPORARY TANK CLOSURE �8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK LS INSTALLED: 2.I IO'8 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.s 1 B. MANUFACTURED BY:C. DATE INSTALLED(MOrDAYNEAR) J �O D. TANK CAPACITY IN GALLONS: "N to 00V ILTANKCONTENTS IFA-I ISMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. L, ❑ Ia REGU R 8 3 DIESELUNLE ❑ B AVMTpN GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM 3 GASAHOL ❑❑ UNLEADED 5 JETFUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ 2 LEADED 9fl OTHER (DESCRIBE IN REM D. BELOVR D. IF(AL1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED _6 V v C.AS.is III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN Box A TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ryryyy�� ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PNmaRT&M) ❑ 9 BRONZE ❑ 10 GALVAN12ED STEEL ❑ 05 UNKNOWN ❑ 99 OTHER E-11 RUBBER LINED [—] 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING INTERIOR C.INE:3Iiy. 5 MASS LINING B UNLINED NING sy ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 6 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,BOT/IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 07 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 90 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM p p a CONCRETE A U 7 STEEL W/COATING A U 8 IOD% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODK3 PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATICLINE LEAK DETECTOR LINE CHTNESS TESTING 3 RITerglTrur90 OTHER ❑ V.TANK LEAK DETECTION MONITORING ❑—/1 VISUAL CHECK ❑ 2 INVENTORY pECONCILIATION ❑ 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING �' TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 97 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAfA SED .2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH �' SUBSTANCE REMAINING _GALLONS INERT MATERIAL YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE URY,AND TO THE BEST OF MY KNOWLEDGE,lS?RUE AND CORRECT APPLICANTS NAME (,PpLIC NTS NA ME DATE„ 1 1� 7�� QVr. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBE IS COMPOSED THE FCVR NUMBERS BELOW STATE 104COUNTY X JURISDICTION a FACILITY p TANK Y 6'L I G p �51014 Z; PERMIT NUMBER PERMIT APPROVED 8Y/DATE PERMIT EXPIRATION DATE OLD FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �b