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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EAC 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 ❑ a TANK REMOVED A DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ` 3 O /V I, TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK 1. 0. # © / B. MANUFACTURED BY: &� �� C. GATE INSTALLED (MO/OAY/YEAR) L(C �" D. TANK CAPACITY IN GALLONS: 6�0 II, TANKC EMS IFA-1 ISMARKED, COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL 9, L. aREGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS UNLEADED E) 2 PETROLEUM Ow EMPTY 1 PRODUCT ❑ 1b PREMIUME7] 5 ASAHOL L ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT E::] 95 UNKNOWN E7] 2 WASTE ❑ 2UNLEADED LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (AJ) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # : III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B, AND C, AND ALL THAT APPLIES IN BOX D ANDS A. TYPE OF ❑ 1 UBLE WALL r-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 NGLE WALL ❑ 4SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Evrl BARESTEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD WIFIBERGLASSREINFORCEDPLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100'/. METHANOL COMPATIBLE WIFRP (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 ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES _ NO— D, CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP ❑ 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. PIPING INFORMATION IRCLE A IFABOVEGROUNDOR U IF UNDERGROUND. BOTH IF APPLICABLE A, SYSTEM TYPE A U SUCTI A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U4CjSINQLE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 ARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 AL MI UM A U 6 CONCRETE A U 7 STEEL W/ COATING A U B 1000/9 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATI LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 I rHiSTIMALgg OTHER MONRORING ❑ V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK Elr2 INVENTORY RECONCILIATION ❑ 3 VADOZE 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/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL ? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PNNTEG d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # SpNJ U L3 STATE I . D .# E PERMIT NUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE lO ldgQ/` �� (7 FORM 9 -91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILE 1 {{////��/iG 7t)