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• \ STATE OF CAIJFORNA ��{J�ry� ` ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B v COMPLETE A SEPARATE FORM FOR E4014 TANK SYSTEM. �1 MARK ONLY I❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ PERMANENT pN ITE 1 ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ g TEMPORARY TANK CLOSUR TANK RE OVE O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0 w ��FFF---+++ I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANKI.D.s I 8. MANUFACTURED BY: /, , — C. DATE INSTALLED(MOOAVfIEAR) D. TANK CAPACITY IN GALLONSv: IL TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ s OIL B. 0. 1a REGUL R I��—{ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ g0 EMPTY ❑ 1 PRODUCT d GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED 5 JETFUEL ❑ 2 LEADED g9 OTHER (DESCRIBE IN REM D. 8EL04Y1 0. IF(A.I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER LJ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001 METHANOL COMPATIBLE'NIFRP (PrimaryTank) I❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING C I UN NIGR F75 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN 719p OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNIC40WN 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR 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 U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ S ML 99 OTHER MONITORING V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 6 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WASTANKFILLEDWITH SUBSTANCE REMAINING GALLONS I INERTMATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT APPLICANTS NAME IPRINtED a AGNANRE) DAT(/�E 7 LJ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ' COUNTY x JURISDICTION x FACILITY n TANK a STATE LD.tk ® y 11 PERMIT NUMBER ERMIT APPROVED 3Y/DATE PERMIT EXPIRATION DATE FORM 8 (9.90) THI§FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F0110(Ol8-Ra