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0 STATE OF CALIFORNIA e�so�,+ee STATE WATER RESOURCES CONTROL BOARD s �`" UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ;" .`m y'< 1 'g COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. Id� d MARK ONLY O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ ONE REM ❑ 2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: y S ,{� q� ❑ a TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN/ r� j �vr A. OWNER'S TANK I.D.• r / �- (/- B. MANUFACTURED BY: G // C. DATE INSTALLED(MO/DAWVEAR) v // /°-' /C� D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. V A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR 3 DIESEL O 2 PETROLEUM 80SAHOL 95 UNKNOWN EMPTY UNLEADED ❑ 6 AVIATION GAS O 3 CHEMICALPRODUCT O Ell 2 WASTE ❑ 1b PREM IUM ❑ 5 GA FUEL UNLEADED ❑ 7 METHANOL D. IF(A.1)IS NOTMARKED, ENTER NAME OFSUBSTANCE STORED ❑ 2 LEADED ❑ 89 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8 - - C,AND ALL THAT APPLIES IN BOX D AND E CA.S.q: A. TYPE OF ❑ ' DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM El2 SINGLE WALL 95 UNKNOWN ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ E STEEL B. TANK 1 BAR ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS MATERIAL ❑ 5 CONCRETE ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ e POLYVINYL CHLORIDE ❑ ALUMINUM (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 9 100% METHANOL COMPATIBLE W/FRP ❑ 98 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING _ C.INTERIOR n 3 EPpXV LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED `,L�9/ 5 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_, NO_ - --- D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING PROTECTION ❑ 3 IN ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNKN UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGR)UND,BOTHEFAPPLICAB ENTION EQUIPMENT INSTALLED(YEAR) A. SYSTEM TYPE A suc7loN p U 2 PRESSURE B. CONSTRUCTION A U 1 SINGLE WALL p U 2 DOUBLE WALL p U 3 GRAVITY p U 99 OTHER A U 3 LINED TRENCH 5 UNKNOWN C. MATERIAL AND A U 1 BARE STEEL p U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE 99 OTHER CORROSION A U S ALUMINUM p U a CONCRETE PROTECTION A U 9 GALVANIZED STEEL p U 10 CATHODIC PROTECT ON 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR U UNKNOWN A U 99 OTHER ❑ 2 LINE TIGHTNESS TESTING V.TANK LEAK DETECTION MONITORING ❑ 99 OTHER ❑ i VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ MATIC TANK GAUGING ❑ 5 GROUND WATA� ONITOgIN, ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DA TE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3 WAS TANK FILLED WITH GALLONS INERT MATERIAL YES ❑ NO❑ THIS FORM HA c BEEN ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF My KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PwmiiI8 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW K;;: PERMIT STATE I.D.# #�n q TANK#PERMIT NUMBER EXPIgATION DATE �• I 0)1 FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. • 3- v cAl • /FOR003448-85 v �/