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l • STATE OFCADFORNIA l/ 6 ,<•pO .° STATE WATER RESOURCES CONTROL BOARD • m.�� <�� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B (/ > � COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONL 1 NEW PERMIT 3 RENEWAL PERMIT 7 PERMANENT C OSED ❑ 5 CHANGE OF INFORMATION 4��1}/ ONE ITEM ❑ 2 INTERIM PERMIT a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE rJ'y. B TANK REMOVED r t; 08A OR FACILITY NAME WHERE TANK IS INSTALLED: e. .a I�, I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN a/ �� 76, A. CWNEtS TANK 1.0.a I B. MANUFACTURED BY: I` //�_--�;�• C. DATE INSTALLED(MCIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS FA-I IS MARKED.COMPLETE ITEM C. REGULA A. 1 MOTOR VEHICLE FUEL ❑ s OIL B. C. ❑ 1aUNLEAOE� 7 DI ❑ 6 AVIATIONGAS ,772 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 10PREMIUM GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED 5 .IETFUEL ❑ 2 LEADED gg OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES AB.ANO C.AND ALLTHATAPPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 7 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (Primary Tank) '❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR LINING U 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ No_ O.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 6 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE 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 V A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 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 [:] I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 w S AL ❑ gg OTHER MoaroawG V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATK)N ❑ 3 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOIDAYNA) 2.ESTIMATED OUANTITY 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 [PAINTED A SIGNATIIP£I DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY Ta7� TANK x STATE I.D.# L_L U PERMIT NUMBER ) 0 PERMIT APPROVED 3YIOATE �i PERMIT E%PIRATION GATE FORM B (944 HIS FORM(MUST BE ACCOMPANIED BY A PERMR APPIJCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORI=IS.M