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1 STATEOFCALIFORNIA •'~-A •• STATE WATER RESOURCES CONTROL BOARD �• ``�� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY1 NEW PERMIT ❑ 3 RENEWAL PERMIT F-15 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM =2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL r-VS- SPECIFY IF UNKNOWN A.OWNERS TANK 1.D.0 B. MANUFACTURED BY: b I C.DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: 11 O OQ� ILTANKCONTENTS IFA•1ISMARKE0.COV".ETErrEMC. 1a REGULAR B 3 DIESEL r 6 AWATION GAS A 1 MOTOR VEHICLE FUEL _ A OIL C. UNLEADED GASAHOL ❑ - METHANOL ❑ 2 PETROLEUM q EMPTY 1 PRODUWASTE ❑ ibPREMIUMI—I 5 JETFUEL ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED lU� 99 OTHER (DESCRIBE N, '-M D-BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF&.55T,ANCE STORED C.A S.a: 1. III. TANK CONSTRUCTION MARK ON'Ei--V ONLY IN BOXES A.8,AND C.AND ALLTHAT APPLIES IN BOX D ANDS A. TYPE OF j2�1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ` B. TANK ❑ T BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS a STEEL CLAD Wr FIBERGLASS REN=ORCED PLASTIC MATERIAL ❑ 5 CONCRETE -I 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W SRP (PrimaryTank) ❑ 9 BRONZE !❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED `'❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING �/ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING T� R LINING MATERIAL COMFAi i3-E WITH 100% METHANOL t YES_ NO— D,CORROSION ❑ T POLYETHYLENE W'Rh 1 2 COATING ❑ 3 VINYL WRAP A FIBERGLASS REINFORCED PLASM PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E3 95 UNKNOWN 4YY55��❑---- 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A :'ABOVEGROUNDORUIFUNDERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U W OTHER 6•n B. CONSTRUCTION A U 1 SINGLE WALL AL17 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U P9 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 9 100% METHANOL COMPATIBLE W1FRP tap PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN Aa 99 OTHERFNul O. LEAK DETECTION I 1 AUTOMATIC LNE LEAK DETECTOR E) 2 LINE TIGHTNESS TESTING ❑ MONITORING 99 07MER J V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCC:ATION ❑ 3 VAOOZE MON17ORING A AUTOMATIC TANK GAUGING ❑ 5 GROUND WA--.R MONITORING ❑ 6 TANK TESTING�o 7 INTERSTITAL MON'CR:NG ❑ 91 NONE ❑ 95 UNKNOWN ❑ M OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST L'SED(IJO.OAYNR) 2.-e STIMATED OCANTITY OF I 3.WAS TANK FILLED WITH NO LYA SUBSTANCE RENAINING WlLONS INERT MATERIAL? --J ❑ �r THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND FTOT BEST MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DA 1PR� 6 IGT N 4---- F/ 66r-4 , /1^J Y LOCAL AGENCY USE ONLY rI THE STATE I.D.NUMBER IS COMPOSED OFTHEFOUR NUMBERS BELOW + COm JURISDICTION x fACILITYx TANK LJ--11 [7J STATE LD.;* r PERMIT NUMBER PERMIT APPROVED BY/DATE PER EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS D C M65{ V, 9CRMB (1291)