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STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD 3 o so UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a�tT COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE e TANK REMOVED 6717 DBA OR FACILITY NAME WHERE TANK IS INSTALLED. 1. TANK DESCRIPTION COMPLETE ALL ITEMS-• SPECIFY IF UNKNOWN A. OWNER'S TANK L 0.s ' B. MANUFACTURED BY: C. DATE INSTALLED(MD/DAYYEAR) D. TANK CAPACITY IN GALLONS; ILTANKCONTENTS IFA-1iS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C ❑ la REGULAR ❑ 3 DIESEL ❑ 6 AVIgTfONGAS UNLEADED 4 GASAHOL ❑ 2 PETROLEUM ❑ E0 EMPTY 1 PRODUCT ❑ lbPRMIUNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a IF III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,6,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100/ METHANOL COMPATIBLE WlFRP (PrIMaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ LINING 5 GLASS LINING t>—C6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER fS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES/��//' NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN 99 OTHER E,SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND,BOTH IFAPPLICASLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION YA SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND BARE STEEL A U 2 STAINLESS STEEL A(^,y3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION ALUMINUM A U 6 CONCRETE ICU 7 STEEL Wl COATING A U B 1009/6 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR2 LINE TIGHTNESS TESTING 3 I IA MONITORING 99 OTHER V.TANK LEAK DETECTION F❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL 91 NONE ❑ 95 UNKNOWN ❑,99 OTHER VI.TANK CLOSURE INFORMATION 1.E T MATED QA LA USED( D6Y R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTS NAME (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW „� � STATE I.D.# COUNTY# JURISDICTION# FACILITY# ANK# PERMIT NUMBER PERMIT APPROVED BYIDATE P RM1T EXP}RATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A C,URy�RENT FORM A HAS BEEN FILED, --f"—y I?—� Y3 FOR0034&R5