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STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD • iy� .a'�'�: UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B '�' COMPLETE A SEPARATE FORM FOR E TANK SYSTEK .MARK ONLY 1 NEW PERMIT F-10 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS- SITE ONE REM 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE C:] 8 TANK REMOVED f,4 / DBA OR FACILITY NAME WHERE TANK IS NSTALLED: D I. TANK DESCRIPTION COMPETE ALL ITEMS- SPECIFY IF UNKNOWN n� A. OWNER'S TANK I.0.t R. MANUFACTURED BY: /'"'C7 C. DATE INSTALLED(MCADAY)YEARI 11�0 I 0. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA•I IS MARKED.COMPLETE ITEM C. la REGULAR i DIESEL OL g AVIATION GAS A. ❑ I MOTOR VEHICLE FUEL ❑ a OIL B. C. ❑ UNLEADED lrJy ❑ ❑ 2 PETROLEUM ❑ 90 EMPTY ❑ 1 PRODUCT ❑ t0�EACIED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ ] CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (CESCRISE IN ITEM 0. BELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANOC.ANOALL THATAPPUES IN BOX 1) A. TYPE OF ❑ I DOUBLE WALL ❑ ] SINGLE 'NALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ B. I BARE STEEL ❑ 2 STAINLESS STEEL r7 ] FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORC-c0 PLASTIC MATERIAL ❑ S CONCRETE ❑ g POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001: METHANOL COMPATIBLE W/FRP (Pdmuy Tani) ❑ 9 BRONZE ❑ 10 GALVANOEO STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ ] -EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ g UNLINED ❑ 95 UNKNOWN ❑ W OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES— NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ ] VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASCVEGRCUNOOR U IFUNCERGROUNO.BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U ] GRAVITY A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U ] 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 2 POLYVINYL CHLORICE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WICOATWG A U S 1001: METHANOL COMPATIBLE'NIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHCCICPROTECTICN A U 95 UN104OWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTCMAT'.0 LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ N vCNRaBu� ❑ 99 OTHER V.TANK LEAK DETECTION F;B SUAL CHECK 2 2NENTOflY RECONCILIATION ❑ ] VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING [:] 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED GATE LAST USED(MMAY/YR) 2.ESTIMATED CUANTITY OF ].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 DATE IPNMFOA S�WM 7 � � 2 LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW -7A/,o COUNTY S JURISDICTICN s FACILITY 9 TANK s STATE I.D.# F3-F U O l PERMIT NUMBER PERMIT APPROVED 8Y10ATE PERMIT-EXPIRATION DATE FORM a (9-9x1 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FORo9HbRA