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STATE OF CAUFORNA STATE WATER RESOURCES CONTROL BOARD iy 1 / UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR r TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYSITE ONE ITEM F-12 INTERIM PERMIT F74 AMENDED PERMITC 8 TEMPORARY TANK CLOSURE S TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 B. MANUFACTURED BY: o(J C. DATE INS TA ED(MOIDAY/YEAR) 1 D. TANK CAPACITY IN GALLONS: V 1I SAI ILTANK NTENTS FA-11S MARKED,COMPLETE ITEM C. 1A REGULAR 3 DIESEL I A. 1 MOTOR VEHICLE FUEL ❑ s OIL B. C. UNLEADED e ❑ 8 AVIATION OAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODLX:T ❑ Ib-Rmum 4 GASAMOL ❑ 7 METHANOL ❑ ❑ ❑ ❑ 2 UNLEADED D Ed 99,ET OTHER L(DESCRIBE IN ITEM D. BELOW) 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1005 METHANOL COMPATIBLE W/FRP (PdmuyTARk) ❑ 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 ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ W OTHER UNWG 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 Q 99 OTHER IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND ORUIFUNDERGROUND.BOTH IFAPPLICASLE A, SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 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 I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE l► CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI 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 ❑ FIT 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 MONRORNAL ❑ 99 OTHER .TANK LEAK DETECTION J ❑ 1 VSUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITLLL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED TE T ED(MOADAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE I�VKtEO a SuixANnE7 - / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / G� STATE LDACOUNTY R JURISDICTION N FACILITY 9 TANK• G27 PERMIT NUMBER / ' PERMIT APPROVED BYIDATE 7 PERMIT EXPIRATION DATE !O FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMB—M