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'�pOVP < STATE OF CALIFORNIA �� oz`s STATE WATER RESOURCES CONTROL BOARD t ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B qa � mi COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. F,4 Q 87 MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT LUKI CHANGE OF INFORMATION ❑ 7 ACLOSEDONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑e DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D a -- I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN I A. OWNERS TANK I.D.# 'aiLf 650V B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: u T AAIV PIIAITCAITC e, vc,rcuc A ❑ 1 MOTOR VEHICLE FUEL 4 OIL EL / REGULAR C. ❑ la eUNLEAD D 3 DIESEL ❑ 8 AVIATION GAS 4 GASAHOL 2 PETROLEUM 80 EMPTY F-1❑ 1 PRODUCT 1b PREMIUM 7 METHANOL ❑ UNLEADED ❑ 5 JETFUEL ❑ ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. 8: III TAMC CONRTNIICTION MARK nNF RTUoiXvw BOXES0.B.AND C. AND ALLTHAT APPLIES IN 80X0 A. TYPE OF ❑ I DOUBLE WALL ❑ SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Q 2 SINGLE WALL ❑ 4 CONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER CONSTRUCTION ❑ 1 BARE STEEL ❑ 2 STAT ESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVI L CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 CALVANI D STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. ❑ 1 RUBBER LINED ❑ 2 ALKYD LININ ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ W OTHER LINING 5 ALUMINUM A U 8 CONCRETE A U 7 STE2kWICOATING A U 8 100% METHANOL COMPATIBLE W/FRP IS LINING MATERIAL COMPATIBLE WITH 10O%METHANOL7 YES_ NO— A U D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUABOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 INED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I BARE STEEL A U 2 STAINLESS STEEL A U 3Plk YVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STE2kWICOATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U li UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECT R ❑ 2 LINE TIGHTNESS TESTING ❑ 31INjOEM5111 G E::]99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOTIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING E:]91 NONE ❑ 96 UNKNO ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTINATJ6D ELAST USED(MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3.WA TANK FILLED WITH JI / //Y SUBSTANCE REMAINING GALLONS ERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTSNAME I DATE (P WNTEU 8 SIGNATURE? LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW U J J'C'L 10,6 3 7 COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# a az�II I :]::� PERMIT NUMBER I PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORMB-PA 04