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a STATE OFCUIFORNA STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FORCH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED p n DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (, (o /l e "th Ap- 19u? d , I. TANK DESCRIPTION COMPLETE ALL ITEMS--SPECIFY IF UNKNOWN A. OWNER'S TANK I.0. B. MANUFACTURED BY: ak C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: "04;70 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETEITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O. ❑ 18UNLEA REGULAR 3 DIESEL ❑ 8 AVIATION GAS A ❑ 2 PETROLEUM ❑ W EMPTY 1 PRODUCT ❑ 10PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARKONE ITEMONLY IN BOXES A.B.AND C,AND ALLTHAT APPLIES IN BOXD A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 NGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimmyTok) ❑ 9 BRONZE ❑ 10 GALV RED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED E__] 2 KVD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% THANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN O 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEG NDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCT N A PRESSU A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U TNG AL A U 2 DOUBLE WALL A U 3 LINED TRENCH A UUNKNO A U 99 OTHER C. MATERIAL AND A U 1 BAAE STEIL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL ATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A N A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 9 MONITORING OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VAP ONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATgAS VEED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO (0 L SUBSTANCE REMAINING GALLONS I INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (VRINTE ANTS AT , LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NU LOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# p / PERMIT NUMBER PERMIT APPROVED BYIDATE IT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00 SN