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. STATE OF CALIFORNIA • �ecw" e, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, n FMARK ONLY FE-11 NEW PERMIT 7 RENEWAL PERMIT ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ITE ❑ ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: •Z, Cel,I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B, MANUFACTURED BY: C. DATE INSTALLED(MO(DAY/YEAR) D. TANK CAPACITY IN GALLONS: (lea ILTANKC ENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ❑ la REGULAR ❑ 2 PETROLEUM ❑ 90 EMPTY PRODUCT G bPREMIOM 8 4 DIESELIESEL Q EO 8 MVEN WNOL AS ❑ S CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE UNLEADED 5 JETFUEL 7 ❑ ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOYn G. IF IA,1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.1: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B•ANOC.AND ALLTHAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL E:] 0 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 ❑ S FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primaryiank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ S EPDXY LINING ❑ 4 PHENOLIC LINING ❑ 5 cuss LINING LINING ❑ 8 UNLINED ❑ 96 UNKNOWN ❑ 9p OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 0 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ g9 OTHER 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 S GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIOE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING PROTECTION A U 9 GALVANIZED STEEL A U 8 1009: METHANOL COMPATIBLE W/FRP A U 10 CATHODIC PROTECTION p B 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINETKiHTNESSTESTING ❑ J IIAMCNRORI AL ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ S VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ S TANK TESTING ❑ 7 INTERSTITIALMONRORING ❑ 91 NONE 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 7.WAS TANK FILLED WITH ❑ GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRIMEO a SIGNATURM DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ,I� PERMIT NUMBEfl ^ EI�y r• 2 v a O PERMIT APPROVED BV/DATE PERMIT P T NOATE FORM B (390) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORo=S-R4 • • v I