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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL 90ARD t•F +� -} UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B h COMPLEI E A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 0 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SI ONE REM 2 INTERIM PERMIT ❑ s AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ORA OR FACILITY NAME'WHERE TANK IS INSTALLED: ,/)U /Z -5 7 / n I. TANKOESCRIPTICN COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.a B. MANUFA qED BY: C. DATE INSTALLED(MWAYNEAR) 0. TANK CAPACITY IN GALLON : II.TANK EMS FA-I ISMARKED.COMPLE7E ITEM C. A. I MOTOR VEHICLE FUEL ❑ A OILB. / C• ❑ IaUNLEAFEGUCED 0 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM El 80 EMPTY y��f 1 PRODUCT ❑ tE PREMIUM A GASAHOL ❑ 7 METHANOL UNLEADED S :ETFUEL ❑ 0 CHEMICALPROOUCT ❑ 95 UNKNOWN Z WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.a III. TANK CONST—RUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF I DOUBLE WALL ❑ 0 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS ❑ A STEEL CLAD 'WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100. METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINGO ❑ 2 ALKYO LINING ❑ 0 EPDXY LINING ❑ A PHENOLIC LINING C.I LINING ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNK,IOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100. METHANOL 7 YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOCIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNCERGROUNO.BOTH IF APDL:CABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U O GRAVITY A U 99 OTHER 9. CONSTRUCTION A U I SINGLE 'HALL A U 2 DOUBLE WALLA U S LINGO TRENCH A U 95 UNKNOWN q U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANfLED STEEL A U 10 CATHCOICPROTECTICN A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ Z LINE TGHTNESS TESTING 1 N SII uL MCNRORING ❑ 99 OTHER V.TANK K DETECTION 1 ISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 0 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MCNITCRWG 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOIUAYNR) 2.ESTIMATED CUANTITY CF O.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLCNS INERT MATERIAL? YES ❑ NO ❑ THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME JP.WEO a SIGNANREI CATE Z LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW WJLS STATE I.D. COUNTY a JURISDICTION I FACILITY A TANK a Em =2 /'� PERMIT NUMBER / O PERMIT APPROVED BY/OATE I PEn'MIT EXPIRATION CATE FORM B (9 w THIS FORM ST BE ACCOMPANIED BY A PERMIT APPUCATION-FORM A,UNLESS A CURRENT FCRM A HAS BEEN FILED. F01100�BaN