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"�c'Paces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i d" / 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 C TE ONE ITEM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E] STANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: v p 905 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN / A. OWNER'S TANK I.O.# I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYYYEAR) -7 Z D. TANK CAPACITY IN GALLONS: O O ILTANKCONTENTS IFA-0 IS MARKED,COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ taUN UNLEADED REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑❑ 4 GAS AHOL 2 PETROLEUM ❑ BO EMPTY ® 1 PRODUCT ® 1bI ED ❑ 5 JETFUEL ❑ 7 METHANOL UNLEADED ❑ 3 CHEMICALPRODUCT ❑ 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALL THAT APPLIES IN BOX D ANDS 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 X 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING fD IS LINING MATERIAL COMPATIBLE 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 INSTALLED(YEAR). OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)_.�_ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AO 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A© 1 SINGLE WALL A U 2 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR VL 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING 9 OTHER V.TANK LEAK DETECTION - - n i VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK G UGING ❑ 5 GROUNDWATER MONITO ING NK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER S gVI.TANKCLOSU EINFORMATION MATED DATE LAST SED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FIL WITH YE NO S.�` SUBSTANCE REMAINING GALL S INERT MATEPI THIS FORM HAS BEEN COMPLt—n UNDER PENALTY OF PERJURY, D TO H ST F N LEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED SIGNATURE) 7 LOCAL AGENCY USE ONLY THE STATE LD.NUM FR IS COMPOSED OF THE FOUR NU ERS 14LOW Z 7 COUNTY# JU ''4DICTION# FACILITY TANK# STATE I.D.# ioe� 00 PERMIT NUMBER PERMIT Af„QR D TE PERMIT EXPIRATION DATE FORM B (7 91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICA N•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. /I 0 (/ 00]dB RS