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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD =� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �cno,•P•� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 7 P NK REMOVED CLOSED ITE ❑ ❑ 8 TEMPORARY TANK CLOSURE /E �/e TANK REMOVED Q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# II— a! B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYIyEAR) D. TANK CAPACITY IN GALLONS: II.TANK CO ENTS FA-I SMARKED,COMpIETEITEM C. A. MOTOR VEHICLE FUEL ❑ 4 OIL B. 1a REGULAR ❑ 2 PETROLEUM ❑ 30 EMPTY 1 PRODUCT C ❑ UNLEADED DIESEL ❑ 6AVIATION GAS El1b❑ PREMIUM 4 OASN OL E] 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNIWOWN ❑ 2 WASTE ❑ UNLEADED 6 JET FUEL ❑ ❑ BE D. IF(A.1)IS OT MAgKED, ENTER NAME OF SUBSTANCE STORED 2 LEADED 99 OTHER (DESCRIIN ITEM D. BELOW) 0.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I SLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM 2 S GLE WALL ❑ 05 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S STEEL00% METHANOL FIBERGLASS EWIFRP REINFORCED PLASTIC (PNmmyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-1I RUBBER LINED 2 AL�1LD LINING C.INTERIOR ❑ 3 EPDXY LINING ❑ 4 P LINING LINING F-1 L.5 GLASS LINING UNLINED ❑ 96 UNKNOWN ❑ W OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 ONE ❑05 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 RSERGLASS PIPE CORROSION A 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U S 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 S IAL ❑ MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 ORMONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ s GROUNDWATERMONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ O❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRN DaSIGNAWM DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# �� STATE LD.# � U v y [PERMITBER PERMITAPPpOVED BY/DATE PERMIT EXPIgATON DATE FORM B(490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0034&RI