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• e\ounces co STATE OF CAUFORMA �� "a STATE WATER RESOURCES CONTROL BOARD i ` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W �� "° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM."I�f°n�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION D. TANK CAPACITY IN GALLONS: (7 Ddd 7PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANKCLOSURE8 1 PRODUCT TANK REMOVED Oq 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: y// S Sx_kia., S'f RIL40N ❑ 95 UNKNOWN nrOn�ll]Tln\I , ,ivue m wv\In4VN A. OWNER'S TANK I. D. / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYA'EAR) NMk D. TANK CAPACITY IN GALLONS: (7 Ddd i V nA\ITL\RC •e, eic iic�� 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 18UN FADED REGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS A. ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT L_]PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE L2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 9 BRONZE C. A. S.8 : ❑ 95 UNKNOWN III TAAIV PnAICTOl IPTInAI AVVnuCISUnNIvINRnYFRA R ANn C. ANDALLTHATAPPLIESINROXD IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IFAPPLICA13LE A. SYSTEM TYPE ❑ DOUBLE WALL r73 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM Lyj SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. CONSTRUCTION 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ s CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E:]8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. MATERIAL AND ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— A U 10 CATHODIC PROTECTION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IFAPPLICA13LE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL AND 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 ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3INTEROflING [7 99 OTHER MON V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 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 1. ESTIMATED DATE LAST USED (MO/DAY/VR) I )2 SUBSTANCE REMAI NG GALLONS STIMATED QUANTITY OF 13 WA INERT M TERIAL? YES ❑ NO ❑ TANK FILLED WITH1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TAN K# STATE I.D.# ® 2 g q O1113[ca.r y+ PERMIT NUMBER PERMIT APPROVED BY/DATE �j)low� FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0031BM 0 0 A/