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STATE OF CALIFORNIA 0 $ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION. FORM B sn a C on , COMPLETE A SEPARATE FORM FO ACH TANK SYSTEM. FDBAOR RK ONLY O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE�%ITE E ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT p� ❑ 6 TEMPORARY TANK CLOSURE e TANK REMOVED FACILITY NAME WHERE TANK IS INSTALLED: IYYLQi Dl b/ OrH/� I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BV: A.OWNERS TANK I.D.# 5 DO D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOIDAV/YEAR) II.TANK CONTENTS IFA-11SMARKED.COMPLETEITEM C. aREGULAR O 3 DIESEL ❑ 6 AVIATIONGAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL a. C. ❑ UNLEADED ❑ 4 GASAHOL 1 PRODUCT 1a PREMIUM ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ UNLEADED ❑ 5 JETFUEL ❑ 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.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX ❑ 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 1 BARE STEEL E] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ a 100% METHANOL COMPATIBLE WIFRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE ETMS PE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER TION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER ND p U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POIWINVI CHLOfl10E(PVC)A U 4 FIBERGLASS PIPE N A U 5 ALUMINUM A U a CONCRETE A U 7 STEE 95/UNKNOWN A U 9910 NERETHANOL COMPATIBLE WIFRPN A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p UECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOfl ❑ 2 LINE TIGHTNESS TESTING ❑ 31 MONROflING STITIAL ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION ESTIMATED TY OF 3.WAS TANK FILLED WITH 2. 1.ESTIMATED DATE LAST USED(MO/DAV/YR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME )PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® FZ D D I D PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT 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. FOROMB- 6