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STATE OF CALIFORNIA coy STATE WATER RESOURCES CONTROL BOARD s`4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT X 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMP"�ORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: &%,-3� l�-FIi ).. 6 ao I TANK(1PCCRIPTIFIN enol cT All ITPUR— RPFCIFY IF I INKNOWN A. OWNERS TANK I.D.# � S. MANUFACTURED BY: 3 DIESEL❑ 8 AVIATION GAS 4 GASAHOL 5 JET FUEL ❑ 7 METHANOL 99 OTHER (DESCRIBE IN ITEM D. BELOW) ' C. DATE INSTALLED(MO/DAYIYEAR) ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) D. TANK CAPACITY IN GALLONS: / O II TANKPANTCNT4 cn enMRI FT➢ITFMR V A 1 MOTOR VEHICLE FUEL E]4 OIL 712 PETROLEUM ❑ N EMPTY ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN g, 1 PRODUCT ❑ 2 WASTE AR C ❑ 1a1REGU DED P EM UM UNLEADED ❑ ❑ 2 LEADED ❑ 3 DIESEL❑ 8 AVIATION GAS 4 GASAHOL 5 JET FUEL ❑ 7 METHANOL 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.0) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. k: III TANK r.nNSTRIICTION MARK nNP ITEM ONIY IN BOXES A.R.AND C. AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER CONSTRUCTION 42_1� BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 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 UNLINED❑ U KNOWN ❑ S9 OTHER LINING 10 CATHODIC PROTECTIO A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES95NO_ 99 OTHER SCLG*' Z , D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ,,��yy �4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV PIPINr INFORMATITON nIRnIF A ICARnVFRROIINn OR U IF UNDFRGROUND. ROTHWAPPLICARLF A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION ANI SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND BARE STEEL A U 2 STAINLESS STEEL A UU3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION 5 ALUMINUM A U 6 CONCRETE A/y .7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTIO A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING 99 OTHER SCLG*' Z , V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑� 2 INVENTORY RECONCILIATION [—]3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING F]6 TANK TESTING u 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. A% ES IMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 4�11 Ep / COUNTY# JURISDICTION# FACILITY# TANK C) STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. lk.., .i %