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m r STATE OF CALIFORNIA " All STATE WATER RESOURCES CONTROL BOARD UNDERGROUNDSTORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. " i 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 DBA OR FACILITY NAME WHERE TANK IS INSTALLED; M E r�_E-10 -FA; 'k< L I N I-5 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYKEAR) D. TANK CAPACITY IN GALLONS: 0 Ob II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. V A 1 MOTOR VEHICLE FUEL 4 OIL B. C. ol la REGULUNLEAR 3 DIESEL 6 AVIATION GAS 2 PETROLEUM 80 EMPTY 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL UNLEADED 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED 0 9L 9 JOTHER (DESCRIBE IN ITEM D. BELOW) D. IF A.1 IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ( ) C.A.S.#: l III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 0 2 SINGLE WALL F--1 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK F-] 1 BARE STEEL El 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-] 5 CONCRETE F-] 6 POLYVINYL CHLORIDE a 7 ALUMINUM 8 1001Y. METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER 1 RUBBER LINED F--] 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR LINING F--] 5 GLASS LINING F-16 UNLINED E:l 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO i D.CORROSION 0 1 POLYETHYLENE WRAP F-] 2 COATING E:l 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-] 5 CATHODIC PROTECTION 0 91 NONE a 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION - A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(92 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING � 'MONfTOTRING ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING 5< 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE E] 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 YES E:] 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 (PRINTED B SIGNATURE) 4JJ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ; COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m 7 � { PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILEN >' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 0.112.91) . � t �a��r�z .,., _ ..,, s "*,, i?..,.1. ... e;^ci..�..A_ ., +�•��r��i-�:; ��- aim' tii■�$ari r Sa��;-u e..'r.,..,_ ,t.,,_ .,. ...`�. " ,.'.�"� _... .., _ '� '�' � '� ,'T'�.,,. p