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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APRICAIIM-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYS MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE 5 K'ii1>^�g ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORA . –, ❑ 8 TANK REMOVED /'5, DBA OR FACILITY NAME WHERE TANK IS INSTALLED: vlh�A I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWNIff A. OWNER'S TANK I.D.• ©/ B. MANUFACTUE03Y; u ti Ii I p r n C. DATE INSTALLED(MO/DAY/YEAR) �i�o�✓17 D. TANK CAPAC'?'N T :731E- /' D J ...) ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. c. ❑ �U>�N:3TM 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT ❑ M7;Jplly —� 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT 4 UNKNOWN ❑ 2 WASTE ❑ 2 �_I 5 JETFUEL '❑ 99 OTHER (DESCRIBE IN ITEM D: BELOYJI D. IF(A.1)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 b 3OXDAOs A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ g(UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEOTANIQ 16 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM { -00% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ;�3 �_UNKNOWN R OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INT ERIOR NIGR ❑ 5 GLASS LINING ❑ 6 UNLINED [2-99–UNKNOWN ❑ 90 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 ❑ 5 CATHODICPROTECTION ❑ 91 NONE UNKNOWN CI 20 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENrCH EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR 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 5 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 85 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONROflING A 99 OTHER ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING1 NONE 85 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 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, IS TRUE AND CORRECT APPLICANTS NAME WAINTED 8 SIGNAT AEI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOU Lpy COUNTY# STATE I.D.# JURISDICTION FACILITY# TANK y PERMITNUMBER PERMITAPPROVVE BBYI1 ATE PER EXPIRATION GATE 9 J –� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORMA HAS BEEN FILED. FORM (12-91) FILE THIS FORM WITH CAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ' FORADHBJN