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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD `±'v4 /' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT E:] 4 AMENDED PERMIT ❑ g TEMPORARY TANK CLOSURE ❑ B TANK REMOVED el DBA OR FACILITY NAME WHERE TANK IS INSTALLED: U-" 'G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a 8. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) L�IL D. TANK CAPACITY IN GALLONS: /o oov II.TANKC LATENTS IF A4 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C- ❑ 1a REGULEO DIESEL ❑ g AVIATION GAS ❑ 2 PETROLEUM ❑ 90 EMPTY 1 PRODUCT ib PREMIUM 4 GASAHOL UNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED II��j D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ !.I OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.a III. TANK CONSTRUCTIONMARKMARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑7LE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 13�1 RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ g POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100X METHANOL COMPATIBLE W/FpP (Primuy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING a UNLINED LINING ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 TNG ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 0 9 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U A U 2 PRESSURE p U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U <SINGLE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN q U 99 OTHER C. MATERIAL AND A U BAREST A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEELW/COATING PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U g 100x, METHANOL COMPATIBLE W/FRP p U BS UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ g TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1,ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAININGYES 3.WAS TANK FILLED WITH GALLONS ❑ INERT MATERIAL? ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT PPLICAMB NAME (P ARINTED&SIGNATURE) DgTE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTIONP FACILITYp eo TANK 11,4 - 4 PERMIT NUMBER PERMIT APPROVED 8Y/OATE PERMIT EXPIRATION DATE (00 (0 9}- FORM 9 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.