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STATE OF CALIFORNIA :`•'"�••.'<° STATE'NATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • . FD COMPLETE A SEPARATE FORM FOO CH TANK SYSTEM i MARK ONLY ❑ 1 NEW PERMIT ❑ 7 RENEWAL PERMIT ff 5 CHANGE OF INFORMATICN 7 PERMANEN SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT C:] 5 TEMPORARY TANK CLOSURE 8 TANK REM VE DBA OR FACILITY NAME WHERE TANK IS NSTALLED: gco N Ebqkz�41 I. TANK DESCRIPTION COMPLETEALLrrEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O.x /E/' S. MANUFACTURED BY: 5(�/V O"I C. DATE INSTALLED(M AWYEAR) 0. TANK CAPACITY W GALLONS: ILTANKCO NTS IF A4 IS MARKED.COMPLETE ITEM C. 111ry{n�Il A. ❑ MOTOR VEHICLE FUEL ❑ A OIL S. C. C] 1tUNLEA ED O DIESEL 2-'[:] 6 AVIATICNGAS V'U 2 PETROLEUM C::] 80 EMPTY 1 PRODUCTIDPREMIUM A GASAHOL 7 METHANOL C:] 7 CHEMICALPRCCUCT C] 93 UNKNOWN CD2 WASTE ❑ UNLEADED 5 JETFUEL ❑ ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C A.S t: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,&AND C.AND ALL THATAPPLIES IN SOX A. TYPE OF ❑ I DOUBLE WALL 0 SINGLE WALL WITH EXTERIOR LINER [�] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ I BARE STEEL 2 STAINLESS STEEL 0 FIBERGLASS A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100Y. METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER I RUBBER LINED ❑ 2 ALXYO LINING ❑ 7 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR LINING 6 UNLINEDCLAM5 CLAM ❑ 93 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH TOC% METHANOL T YES— NO_ D.CORROSION ❑ I POLYETHYLENE WRAP Q 2 COATING a 0 VINYL WRAP O A FIBERGLASS REINFORCED PLASTIC PROTECTION a 5 CATHODIC PROTECTION ❑ 91 NCNE Q 95 UNKNCWN Q W OTHER I .PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNCERGROUND.BOTH IF APPLICABLE =SYSTEMPE A U i SUCTION A U 2 PRESSURE A U 2 GRAVITY A U 99 OTHER TION A U I SINGLE WALL A U 2 DOUBLE WALL A V 0 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER ANO A U I BADE STEEL A U 2 STUNLESS STEEL A U 2 PoLYVINYL CHLORIDE(PVC)p U • FIBERGL4SS PIPE N A U S ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 IOOf: METHANOL COMPATIBLE W/FRP N A U 9 GALVANrZEO STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER CTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ] :K ML ❑ 99 OTHER 4CNROPWG ''/V.TANK LEAK DETECTION 1' ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 2 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONNTORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED D? LAST�U§EgfMWOAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING O.WAS TANK FILLED WITH YES ❑ NO ❑ GALLONS INERT MATERIALT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PMWED a SIGNAL Ra) DATE LOCAL AGENCY USE ONLY THE STATE LO.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTIONx FACILITY x Tx dl. 3�STATE I.D. m-� 0 �, ANK 1010)94 PER IT YU BER LIZAl I PERMIT APPROVED BY/DATE PERMIT EXPIRATION OATE -- '/ FORMS (4901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. :I, fORomNbM