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'�booa e STATE OF CALIFORNIA '"� STATE WATER RESOURCES CONTROL BOARD F ° UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B w m� v COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ��"�� FlaMJ7�T / /a Q7 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ONE ITEM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 8 TEMPORARY TANK CLOSURE ❑ ❑ 7 PERMANENTLY CLOSED O E 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -970-1 O 1b PREMIUM ❑ 7 METHANOL FUEL ❑ S JETHER ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S.0: 2 STAINLESS STEEL ❑ 3 FIBERGLASS 7d A. OWNERS TANK I.D.# T B. MANUFACTURED BY: POLYVINYL CHLORIDE 7 ALUMINUM ❑ ❑ yv C. DATE INSTALLED(MO/DAY/YI D. TANK CAPACITY IN GALLONS: ❑ GALVANIZED STEEL ❑ 95 UNKNOWN fA O 11 TAAIV PYTMTLMTQ ICA_I I,CuA RICCn rIIMP--`CeTP ITFMC V --M A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. / to REGULAR n 3 DIESEL C. ❑ UNLEADED Iu—I ❑ 8 AVIATION GAS 4 GASAHOL ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT O 1b PREMIUM ❑ 7 METHANOL FUEL ❑ S JETHER ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ ❑ 9B OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S.0: 111 TAMIL PYIMCTGIICTIOM uARHnNP ITPMnNIYINRnYPRA R. ANn C. ANO AI. I. THAT APPLIES IN BOXO 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 B. ❑ / BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 6 CONCRETE POLYVINYL CHLORIDE 7 ALUMINUM ❑ ❑ ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrlmaryTaAA) ❑ 9 BRONZE ❑ GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ / RUBBER LINED❑ 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR INTERIOR❑ 5 GLASS LINING ❑ 6 U INED ❑ 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% ETHANOL? YES_ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATI ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCIE A IF ABOVE GROUND OR U IK UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUR A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE W L A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 BARE STEEL A U 2 STAINLESS S EL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROT TION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE T TNESS TESTING ❑ INTERSTITIAL ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONIT ING❑ 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. ESTIMAT,WTE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH Y ❑ DU ❑ A/ LL 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 8 SIGNATORE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW LV ff L //l COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER I PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE FORM B (9-9D) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. P-1 //-as-F/fp,