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_ STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT F_j 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED j <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# =L S. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO'DAV/YEAR) LA ­A 'D. TANK CAPACITY IN GALLONS: 7o 3oo <br /> II.TANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> ® 1 MOTOR VEHICLE FUEL 0 4 OIL B. C. to REGULAR 3 DIESEL 6 AVIATIONGAS <br /> A. UNLEADED 4 GASAHOL ID <br /> O 2 PETROLEUM O 80 EMPTY ® 1 PRODUCT 1bUNLEAIDED Q 5 JETFUEL ] METHANOL <br /> O 3 CHEMICAL PRODUCT Q 95 UNKNOWN O 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.ANDC,AND ALLTHAT APPLIES IN BOXDANDE <br /> A. TYPE OF ® 1 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER <br /> O 1 RARE STEEL 0 2 STAINLESS STEEL ® 3 FIBERGLASS a 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL Q 5 CONCRETE 6 POLYVINYL CHLORIDE O ] ALUMINUM O 6 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) O 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN W OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING <br /> --' C.INTERIOR O 5 GLASS LINING 6 UNLINED F-1 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES.,� NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION Q 91 NONE O95 UNKNOWN a 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) I 1' ( I OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 1179 7 <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A CLL' 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A Q)2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A(g) 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELAV/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION © 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING I] 3 INTERSTITIAL <br /> MONITORING Ej 99OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING D 4 AUTOMATIC TANK GAUGING 0 5 GROUNDWATER MONITORING <br /> O 6 TANK TESTING ® 7 INTERSTITIAL MONITORING E] 91 NONE Q 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES O NO O <br /> SUBSTANCE REMAINING GALLONS I INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANPS NAME DATE <br /> (PfllMEOa SIGNATUFEI 4 ` - <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# m I I I I J -I I <br /> PERMITNUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE <br /> FORM B (7.91) THIS FORM MUST BE ACCOUD BY A PERMIT APPLICATION•FORMA,UNLESS A CrjT FORMA HAS BEEN FILED. <br /> FO9WNB46 <br /> 717-V/& <br />