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T • STATE OF CALIFORNIA • '� STATE WATER RESOURCES CONTROL BOARD " 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B . 11 ° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Q 2 OBAOR FACILITY NAMEWHERETANKISINSTALLED: Ljp/ W Lv4:� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# 0 S. MANUFACTURED BY: K, C. DATE INSTALLED(MO/DAY/YEAR) 1-777— 0. TANK CAPACITY IN GALLONS: p 0Q 0 II.TANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C. E::] 1e N EADEO 3 DIESEL ❑ g AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY ��J/1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL NLEADED ❑ 5 JET FUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E::] 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.# III. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF �❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN JQ 2 SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 AL LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO—/ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F--15 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENTINSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION p RESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL ANSTEEL A U 3 POLYVINYL CHLORIDE(PVC) U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP D A U 1 BARE STEEL A U 2 STAINLESS PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINELEAK DETECTOR ❑ 2 LINE TIGHTNESSTESTING ❑ INTERSTITIAl 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑�yC VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATICTANKGAUGING ❑ 5 GROUNDWATER MONITORING u V TANK TESTING F77 INTERSTITIAL MONITORING ❑ 91 NONE E] 95 UNKNOWN E::] 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUSSTANCEREMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTEDaSI.NA, E) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW STATE I.D.# git COUNTY# JURISDICTION# FACILITY# TANK# I I I I 1??6--- ic PERMITNUMBER ERMITAPPROVEDBY/GTHIS FORM MUST BE ACCOMPANIED BY A PERMITCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORME (1291) A