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un e • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY If1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS r/ ONE ITEM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L/10 tvcs e-,q, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.R / B. MANUFACTURED BY: vn C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: O ILTANKCONTENTS IFA-1 ISMARKED,COMPLETE ITEM C. �F✓d,�, 0 (,, (4 u � n k- A. �l MOTOR VEHICLE FUEL ❑ / OIL B. C.�I UNLEADEEGULAR PEMIUMD ❑ 3 DIESEL ❑ g gy1p710N GAS ❑ 4 GASAHOL O 2 PETROLEUM E::] go EMPTY PRODUCT ❑ 1bUNLEADED ❑ 5 JETFUEL L] 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.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑�/1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM ISI 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK F-11 BARE STEEL ❑ 2 STAINLESS STEEL E:] 3 FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ g 100% METHANOL COMPATIBLE W/FRP (PrimaryTok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E]-9g UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �95 UNKNOWN ❑ 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 E;ojlSUNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A IV 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 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 STE W/COATING A U 8 10D% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A3 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR QT LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑gg OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? VES ❑ NO El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# Q.4INw YL STATE I.D.# 3 F91 = I I 0lvlsls---1 I I I I livill PERMITNUMSER PERMITA 7OVEDBY/DATE PERMIT EXPIRATION DATE 3 FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �] FORUW BRI