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• STATE OF CALIFORNIA .r.9 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B ?n GCOMPLETE A SEPARATE FORM FOR Ep TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED G� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: O 5 /'7i 1-L /! P / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN / A. OWNER'S TANK I.D.# 3 B. MANUFACTURED BY: �, �,�AV C. DATE INSTALLED(MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: © ©0 ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. REG eta A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 3 DIESEL C• .Ll UNLEA EO O 4 GASAHOL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 60 EMPTY ��PROOUCT ❑ 1bUNLEAID D ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 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.S.AND C,AND ALL THAT APPLIES IN BOX O AND L] 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER L] 95 UNKNOWN A. TYPE OF SYSTEM LSI 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ARE STEEL ❑ 2 STAINLESS STEEL -] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ��B S. TANK5 CONCRETE F—] 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED [�NKNOWN ❑ 99 OTHER LINING 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 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A / 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 1DO% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER INILKWIIIAL D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING Fe� 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 MONITORING La-M NONE ❑ 95 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 ❑ N L 2 Z THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 4 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# `�[,AAge— STATE I.D.# � p p 55 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATION DA TE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0036BR5 0 /� 0