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• STATE OF CALIFORNIA • �' STATE WATER RESOURCES CONTROL BOARD iy •`'n�� , G UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. _ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Etrs CHANGE OF INFORMATION 11 7 PERMANENTLY CLO SI ONE ITEM ❑ 2 INTERIM PERMIT a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK q MOVED L DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 257 l `L-3-76 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.0.a /]_ BMTANK TURED BY: / C. DATE INSTALLED(MC/DAY/YEAR) O I J DACITY IN GALLONS: L II.TANK CO EMS IF A4 IS MARKED,COMPLETE ITEM C. A. I MOTOR VEHICLE FUEL ❑ A OIL B. Jr C. a REGULAR 3 DIESEL ❑ g AVIATIONGAS ❑ 2 PETROLEUM ❑ 00 EMPN �� PROOl1CT lb PREMIUM 8 A GASAHOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED LEAD D ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IS(A.1)15 NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ %DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Lr_YI/2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100Y. METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER IV,PIPING INFORMATION CIRCLE A IF ABOVE GROUND 08 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 U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 I I WL ❑ g9 OTHER MONITORING V.TANK LEAK DETECTION I 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 1 ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONEFi�sUNKNOWN ❑ 99 OTHER 1 VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USE AY/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOTHE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED A SIGNATUpE) DATE was LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LD. = Z s o o , o COUNTY a JURISDICTION 8 FACILITY R TANK 9 PERMIT NUMBE A,I /LAB PERMIT APPROVED BYYIOATE PERMIT EXPIRATION DATE FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR88118-R/