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STATE OF CAUFORTMA c� i STATE'NATER RESOURCES CONTROL BOARD t 7 1,„ �'; v/ UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �s COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. .. .y. o MARK ONLY ❑ I NEW PERMIT S RENEWAL PERMIT ❑ 7 PER,"E '- ❑ S CHANGE OF INFORMATION CLO _ SIT.- ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE CDB TANK RE VE •� OSA OR FACILITY NAME WHERE TANK IS INSTALLED: I IU I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY A UNKNOWN A. OWNEWS TANK L 0.s 1-- ! a. MANUFACTURED BY: s 61Z 4 DATE INSTALLED(M AYNEA)1) I I 0. TANK CAPACITY N GALLONS: If.TANK CO NTS IFA IISMARKED.CCMPLET9ITEMC. A. MOTOR VEHICLE FUEL ❑ a O0. g, I C ❑ Ia REGULAR S DIESEL 'f/ UNLE40ED ❑ e AVUTCN GAS 2 PETROLEUM ❑ 90 ENPTV 1 PRCOIJCT ❑ 1D PREMRUM a GT_UEL ❑ ] .METHANOL ❑ 7 CHEMICALPROCUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED Q 5 JET FUEL ❑ 94 OTHER (DESCRIBE W ITEM 0. BELOYq 0. 6(A.11 IS NOT MARKED. ENTER NAME OF SUBSTANCE STOPED C.A.S.s: III. TANK CONSTRUCTION MARK ONE REM ONLY N BOXES A.3.ANOCW AND ALLTHATAPPUES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 2 SINGLE WALL WITH EXTERK)R LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 2 FIBERGLASS ❑ A STEELCLAO 'Ni FIBERGLASS REINFORCED PLASTIC MAT ERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100Y• METHANOL COMPATBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ C INTERIOR 2 EPDXY LINING A PHENOLC LINING ❑ 5 MAW LINING C:] e UNLINED ❑ 95 UNKNOWN ❑ ❑ 9D OTHER IS LNNG MATERIAL COMPATIBLE WITH 100% METHANOL? YES—D. ED.CORROSION ❑ 1 POLYETHYLEENE WRAP [:] 2 COATING ❑ 0 'AMYL WRAP ❑ a FIBERGLASS REINFORCED PIASTC PROTECTION ❑ S CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ N OTHER I .PIPING INFORMATION CIRCLE A FABOVEGROUNOOR U FUNCERGROUND.30THIFAPPLICAeLE A. SYSTEM TYPE A u I SUCTION A U 2 PRESSURE A U 2 GRAVITY A U 99 OTHER I\ B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UNK40WN A U N OTHER n\\ C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 2 POLYVINYL CHLORIDE(PVC(A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEELWW COATWG A U 3 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 2 GALVANIMO STEEL A U 10 CATHCOICPROTECTICN A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ O AYCROWRWO ML [790 OTHER N V.TANK LEAK DETECTION 1, ❑ 1 VISUAL CHECK ❑ 2 INVENTORY REOONC2.uTKON ❑ 2 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGWG ❑ S GROUND WATER MCNITCRNG ❑ 5 TANK TESTING ❑ 7 NTERSTRIALMONRORNG ❑ 91 NONE ❑ 95 UNMIOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2ESTIMATEO CUANTITY OF 2.WAS TANKFILLEO WITH SUBSTANCc'REMAINING GALLONS WERT MATERIAL] YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO ME BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT APPLICANTS NAME DATE LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW-�75 STATE I.D. COUNTY 9 JURISDICTION t FACILITY 9 TANK 2 PERMIT NUMBER LIZA-II PERMIT APPROVED BYIOATE PERMIT EXPPII—RAATION�CATE1�� FORM B *M THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Fanamlapa v