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STATE OF CALIFORNIA �� STATE WATER RESOURCES CONTROL BOARD i' � ° UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B "�� 'e •e•CSI��O�> . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT F7 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY �'^��^=y`,'SI ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 u, fl. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN L A. OWNER'S TANK I.D.# B. MANUFACTURED BY: L C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: eel ILTANKCONJENTS FA4 ISMARKED,COMPLETE ITEM C. t MOTOR VEHICLE FUEL ❑ 4 OIL B. C. WELGULAR 3 DIESEL ❑ 6 AVIATIONGAS A. ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ lb PREMIUM 4 JET FUEL ❑ 7 METHANOL UNLEADED E::] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED99 OTHER (DESCRIBE IN REM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 0.A-S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ t LE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S. TNK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimmyTAAk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 1NKNOWN ❑ 98 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 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL T VES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF A80VE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE SUCTION PRESSURE A U 3 GRAVITY A 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 ST WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING Q 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 AL CHECK Efr2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITUILMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ S9 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDOUANTITYOF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL T ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND 70 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE IPRNTE9 A SWNATUAEI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW f COUNTY# JURISDICTION# FACILITY# 3q 3_� �,TANK# QD C (/L�13 STATE I.D.# ® lolo �2M 1141 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. WpW1{BRI