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♦ STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 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 ❑ 7 PERMANENTLY CLOSED ONqfTF ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a TANK REMOVED (}. OBAOR FACILITY NAME WHERE TANK IS INSTALLED: L-nd-4:17 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.8 B. MANUFACTURED BV: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. O ❑ la REGULAR EGR 3 DIESEL ❑ 6 AVIATIONGAS �Mp 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 TV ❑ 1 PRODUCT ❑ 1bULEADED ❑ 5 JETFUEL ❑ ? METHANOL ❑ 3 CHEMICAL PRODUCT ILI•G1�"'/UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1DOUB WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM F-12 SINGLE ALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE$TEE ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F75 CONCRETE ❑ 6 POLYVINYL CHLORIDE 717 ALUMINUM ❑ 8 10D% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 00 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING F-] 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED F-] 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATI E WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTAL ED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVEG UNDORUIFUNDERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U I SUCTION A U\2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 TAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 NCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 C THODICPROTECTION A U 96 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTINGIE ❑ 3 MONRORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 7 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 DOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 N E ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY F 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAININ GALLONS INERT MATERIALT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, ND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A2HAS BEEN FILED. C) �0`0l 9 BRa